Resistance to cis-diamminedichloroplatinum(II) (cisplatin), a DNA damaging agent, is a major obstacle for its clinical effectiveness. Multiple mechanisms may be involved in cisplatin resistance. Frequently cited mechanisms include reduced accumulation, elevated levels of glutathione (GSH) and metallothionein, and enhanced DNA repair. Alterations in oncogene expression and in signal transduction pathways involved in apoptosis have been associated with cisplatin resistance. Of these mechanisms, decreased accumulation of cisplatin is the most common finding. Efflux of cisplatin by an organic anion transporter has been proposed, and one of the organic anion transporters, canalicular multispecific organic anion transporter, is associated with cisplatin resistance. Sensitivity to cisplatin has been increased by inhibitors of DNA repair, agents that increase accumulation of cisplatin and depletion of GSH. None of the agents tested that modulate cisplatin sensitivity completely reverses cisplatin resistance. These observations indicate that multiple mechanisms of resistance arise in the same cell line when cells are selected in vitro.