Participant Information and consent form

Expression and regulation of efflux transporters in chemoresistant cancer cells in

Bangladeshi patients

1. Sample ID : BCO #
2. Name :
3. Age : _ _ _ _ _ _ _ _ years _ _ _ _ _ _ _ _ months
4. Gender : Female Male Others
5. Cancer type : Breast Colon Ovarian

Others, Please specify: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

6. Current :
anticancer 1. Drug: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Dose: _ _ _ _ _ _ _ _ _ times/day
drug
regimen 2. Drug: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Dose: _ _ _ _ _ _ _ _ _ times/day

3. Drug: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Dose: _ _ _ _ _ _ _ _ _ times/day

8. History of : No Yes
recurrence
If “Yes”, recurrence after : _ _ _ _ _ years _ _ _ _ _ months
Previous cancer type(s): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
8. Previous : 1. Drug: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Dose: _ _ _ _ _ _ _ _ _ times/day
anticancer
drug
regimen 2. Drug: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Dose: _ _ _ _ _ _ _ _ _ times/day

3. Drug: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Dose: _ _ _ _ _ _ _ _ _ times/day

9. Other :
diseases Disease name(s): 1. _ _ _ _ _ _ _ _ _ _ _ _ _ _ 2. _ _ _ _ _ _ _ _ _ _ _ _ _ _
and
current 1. Drug: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Dose: _ _ _ _ _ _ _ _ _ times/day
drug
regimens 2. Drug: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Dose: _ _ _ _ _ _ _ _ _ times/day

3. Drug: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Dose: _ _ _ _ _ _ _ _ _ times/day

4. Drug: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Dose: _ _ _ _ _ _ _ _ _ times/day
10. Smoking : Yes No For: _ _ _ _ _ _ years
habit

Approval and signature of the participant: Yes No

__________

Page 1 of 2
 Information for the participant
Title of the Research Project
Expression and regulation of efflux transporters in chemoresistant cancer cells in
Bangladeshi patients

Purpose of the Study

Breast cancer affects nearly 1.5 million women worldwide every year, making it the most
common cancer in women. Colorectal cancer is another highly prevalent malignancy across
the world and a leading cause of cancer-related deaths. Ovarian cancer is also one of the
most common gynecologic malignancies. Epidemiologic studies have demonstrated a
tendency for breast, ovary and colon cancers to aggregate in families.

Although the development of new therapeutics has significantly reduced mortality rates
from these cancers, development of resistance against therapeutics is still a major problem.
Over 25% of the patients with early-stage breast cancer have recurrence and resistance to
therapeutics. Almost 50% of the patients with colorectal cancer suffer from recurrence.
About 20%-30% of the ovarian cancer patients do not respond to chemotherapy. In this
study, we shall investigate the molecular mechanism of chemoresistance in breast, colon
and ovarian cancers.

Cancer is predicted to become an increasingly important cause of morbidity and mortality

in Bangladesh in the next few decades. The International Agency for Research on Cancer
(IARC) has estimated cancer-related death rates in Bangladesh to be 13% in 2030. Based on
the global age-standardized incidence and mortality rates breast, ovarian and colon cancer
are positioned within the top 10 cancers in Bangladesh. Responses to different drugs vary
across populations. In addition to shedding more lights on the up-regulation mechanism of
MDR1, MRP1 and ABCG2, this study will generate a Bangladeshi population specific
chemotherapeutic drug-response related profile, which may help prescribing more
appropriate drugs for the relevant cancers.

Page 2 of 2