There is a clear need for additional protection for oncology professionals. However, cost and awareness are still barriers to widespread adoption. A major barrier to widespread adoption of CSTDs is the cost of these devices. 

Using a closed system is more expensive than a regular syringe, and the systems are single-use devices. This cost, for many hospitals, is prohibitive, and thus many facilities are opting out of using CSTDs.

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Furthermore, health care professionals often do not know about other routes of exposure, specifically when it comes to the vapors and aerosols that can escape into the environment. Many believe that the other protective measures, such as using PPE, clean rooms, and biological safety cabinets are sufficient.

However, clinical studies that have tested for surface contamination have found significant levels of hazardous drug residue around the workplace with existing safety measures.2

The lack of awareness surrounding hazardous drugs compounded with the high upfront cost serve as barriers to adopting such devices.

Despite these barriers, there are several drivers pushing forward CSTD adoption, including:

  • Regulatory
  • Moral
  • Cost savings
  • The fear of legal action

As noted, there are many regulatory bodies and industry associations that are pushing for stricter regulations for safe handling practices in the workplace. The states of Washington, California, and, most recently, North Carolina, have passed new legislation that supports the growing trend toward CSTD use. These states as well as others are taking a closer look at documents like USP <800> to find ways to increase safety for health care workers.

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As awareness of the dangers of exposure to hazardous drugs increases, the moral imperative to improve workplace safety also grows. Ernie Anderson, MS, RPh, a health care consultant, was quoted in an article earlier this year stating, “to protect the safety and well-being of your workers is one of the most important duties you have as a pharmacy director.”1

While the moral imperative to implement the use of CSTDs is clear, there is also a financial benefit to CSTD adoption. The high cost of chemotherapy drugs has risen sharply over the past decade.3 While an overwhelming majority of health care facilities cite cost as the main barrier to CSTD adoption, CSTD expert James Jorgenson stated that for every $1 spent toward CSTDs, health care facilities have $5 of potential savings.1

These savings can be found through new efficiencies brought about by CSTD use. For example, a process known as drug vial optimization keeps chemotherapy drugs uncontaminated for a longer period of time. This allows oncologists to make the most out of every vial of expensive chemotherapy drugs, resulting in hundreds of thousands of dollars in savings for individual facilities, and exponentially more savings nationally.1

Furthermore, hospitals can save money by investing in CSTDs now, and making sure that they provide employees who come in contact with hazardous drugs all have the protection they deserve. If health care facilities invest in the highest forms of protection for their employees, they can avoid paying major sums in the event of lost court cases or out-of-court settlements brought by current or former employees who could sue for lack of adequate protection against hazardous drug exposure.

As the oncology community continues to be educated on the importance of using CSTDs, there will certainly be more widespread adoption of these devices. And as more research is conducted to demonstrate the efficacy of CSTDs as a key protective measure in oncology practice, we will see CSTDs become a necessary requirement in even more facilities, rather than simply an added protective measure.

Marino Kriheli is cofounder of Equashield. Equashield’s industry leading CSTD systems have been cleared by the FDA under the ONB product code, and substantiated to FDA and defined in FDA cleared labeling as preventing microbial ingress up to 7 days.


  1. Pharmacy Practice News. Do CSTDs need more attention in health systems? Published May 2014. Accessed October 14, 2014.
  2. Clark BA, Sessink PJ. Use of a closed system drug-transfer device eliminates surface contamination with antineoplastic agents. J Oncol Pharm Pract. 2013;19(2):99-104.
  3. Rabin RC. Chemo costs in U.S. driven higher by shift to hospital outpatient facilities. Kaiser Health News. Published May 6, 2014. Accessed October 14, 2014.