The term multidrug resistance is defined in this article as cellular resistance to anticancer agents due to a decreased concentration of active drug at the target sites that is caused by increased metabolism or altered transport or routing of the active drug species. Resistance related to alterations in the drug targets or apoptotic pathways is not discussed. Until recently multidrug resistance was associated almost exclusively with p-glycoprotein (Pgp)-overexpression. However, other non-Pgp-related mechanisms have been tracked down. It has been shown that transfection of the gene that encodes a novel drug transport protein, the multidrug resistance protein, induces cross-resistance for many multidrug resistance drugs as well as active transport of daunorubicin from tumor cells. Surprisingly, it has also been found that multidrug resistance protein mediates transport of negatively charged species that are not classic multidrug resistance drugs, such as leukotriene C4 and other glutathione conjugates as well as negatively charged dyes. It was therefore suggested that multidrug resistance protein is identical with the multispecific organic anion transporter. The transport rate of several positively charged drugs (vincristine, rhodamine-123, daunorubicin) by multidrug resistance protein appeared to be dependent on the cellular glutathione levels. Multidrug resistance protein seems to be constitutively expressed in normal tissues at a low level with few tissues having higher expression. Multidrug resistance protein overexpression in in vitro-selected MDR cell lines occurs relatively frequently in lung cancer and leukemia cell lines and often precedes Pgp overexpression. Differential expression has been demonstrated in tumor samples, which suggests a role in resistance to chemotherapy in at least certain tumor types. Modulation studies of multidrug resistance protein activity are still scarce. Other non-Pgp, non-multidrug resistance protein multidrug resistance mechanisms probably exist but have not been identified at the molecular level as yet.