We interviewed Wenora Johnson, a stage III CRC survivor to shed light on the numerous barriers for diverse populations to enroll in clinical trials, and how the community can work together to address these challenges.

People who are underrepresented in health care are generally likely to also be underrepresented in clinical research. We recognize that clinical trials are arguably the most important step to transition research into the real world, providing benefits across disease states, and improving health outcomes throughout various populations.

Looking at the demographics of clinical trial enrollees, Black Americans make up approximately 18% of enrollees, while Latinx/Hispanic populations represent a mere 6% of trial participants. In nearly two-thirds of clinical trials, there is zero representation from Indigenous communities. We continue to see low enrollment numbers in spite of the fact that Black Americans and Indigenous populations have a higher risk of developing colorectal cancer (CRC) compared with Caucasian counterparts.

Q: From your perspective, what do you see as the greatest barriers for diverse populations enrolling in clinical trials?

A: From my perspective, the greatest barriers include:

• Distrust of the medical system/research that goes back to the Tuskegee Syphilis experiment
• Fear that they will be guinea pigs and that physicians wouldn’t care if something happened to them
• Lack of access to health care and facilities and quality insurance coverage
• Provider perception (bias and false perceptions) about people of color – e.g., that they are less educated, and therefore, less likely to adhere to clinical protocol, as well as the assumption that people of color wouldn’t like to participate in clinical trials, rather than asking them
• Concern that a person of color would get a placebo and a white person would get the real medication
• Lack of education on clinical trials – people of color need to learn more about clinical trials so they can make an informed decision

Q: When you were diagnosed with CRC, did you consider searching for clinical trials? What was your experience like?

A: I was diagnosed with stage IIIb CRC. While the standard treatment of care was surgery and six months of chemotherapy, I was very open to the idea of clinical trials. In fact, I did some research on the ClinicalTrials.gov website to see what the latest options for CRC were in 2011.

Since my standard treatment plan worked, and I’ve had no evidence of disease, I keep an open mind for clinical trials due to my Lynch Syndrome diagnosis. A recurrence of CRC can happen at any time and I want to be armed with the latest knowledge available.

Q: How do you use your expertise to help others find clinical trials?

A: One of the best opportunities I’ve had as a patient advocate is to be a curator for the Fight CRC Clinical Trial Finder. It served a dual purpose.

It allowed me to better understand treatment options such as immunotherapy and also how genetics play an important role in treatment options and understanding tumor markers. It also helped me become a better spokesperson on clinical trials to people of color. This means helping others understand and dispel myths associated with clinical trials and guiding individuals to use trial finders like the Fight CRC Clinical Trial Finder.

Q: What can researchers, advocacy orgs and others in the cancer sphere do to reduce barriers and make it easier for minority communities to find and enroll in clinical trials?

A: Barriers can be reduced for minority communities by:

• Providing accurate information about the clinical trials process using social media, pamphlets, and nurse navigators to help patients understand, as well as dispelling myths associated with clinical trials.
• Showing minority representation in advertisements regarding clinical trials
• Addressing language barriers – translating into other languages
• Providing pop-up clinics in economically depressed areas where health care staff can answer questions and/or concerns patients may have
• Providing possible financial incentives to help offset costs associated with clinical trials.
• Making sure that diversity, equity, and inclusion is truly taking place for all patients.

If you’re a colorectal cancer patient, you might have seen the acronyms “MSI” and “MSS” in reference to tumor testing. Colorectal cancer tumors are often referred to as having an “MSI status,” meaning they will either be MSI or MSS – they will not be both.

All colorectal cancer patients should get their tumors tested and know their MSI status. Talk to your oncologist and surgeon.

Your doctor will be the one to request a test to determine your MSI status. This often occurs during the surgery that removes your tumor, but it can be done afterward as well if it was not initially performed. The outcome of your test will show your MSI status as either “MSI-high (MSI-H)” or “MSS (non-MSI).”

MSS

MSS stands for “Microsatellite Stable.”

Approximately 80-85% of colorectal cancer patients are not MSI-H/MMR deficient and are instead classified as MSS.

MSS tumors have been referred to as “cold” tumors, which means they don’t normally trigger a strong response from the body’s immune system. In terms of the number of tumor genetic mutations, MSS tumors are typically less mutated than MSI-H tumors. In general, non-MSI tumors do not respond to immunotherapies.

These tumors often exist in an environment that suppresses the immune system. Research continues to study ways to effectively treat MSS tumors.

If you have MSS metastatic disease, request testing for additional biomarkers including KRAS/NRAS, BRAF, and HER2. Knowing your biomarkers can help your doctors identify your best treatment options and help you make well-informed decisions about how your cancer will be treated.

Learn more about the MSS biomarker.

MSI-H

MSI stands for “Microsatellite Instable.” MSI-H means that there is a high amount of instability in a tumor.

MSI-H results when genes that regulate DNA (called Mismatch Repair Genes) don’t work correctly. Mismatch Repair Genes (MMR) work like genetic “spell checkers” by correcting errors in DNA as cells divide, similar to how “spell checkers” correct typos on a computer.

When MMR genes stop functioning at their highest potential, areas of DNA could start to become unstable due to the errors.

An MSI screening test looks for changes in the DNA sequence between normal tissue and tumor tissue and can identify whether or not there is a high amount of instability, which is called MSI-High.

MSI-High is found in about 15% of CRC tumors. It is often in tumors associated with the hereditary syndrome, Lynch syndrome, though many MSI-High tumors are sporadic (not due to a hereditary syndrome). Patients who test MSI positive are considered to have an MSI-High tumor.

An additional test (immunohistochemistry test) is often used to make the distinction between hereditary and nonhereditary MSI-High because if it is hereditary (meaning the patient has Lynch syndrome) there is a risk that their family members could also have it, therefore is an increased chance of developing colorectal or other tumors. If Lynch syndrome is the cause of an MSI-High tumor in a patient, their immediate family members can talk to their doctors about testing for Lynch syndrome.

MSI-high tumors can attract the attention of the immune system. Under a microscope, large numbers of immune system cells can often be seen in these tumors. The immune cells are just being blocked from fully doing their job. Many patients with MSI-H tumors have had a positive response to immunotherapy treatments (or immune-checkpoint therapies). Therefore, knowing your MSI status is extremely important prior to selecting a treatment.

Read more about the MSI-H biomarker.

More about Biomarkers

MSI and MSS are two biomarkers out of many that can impact a colorectal cancer patient’s treatment plan. Learn more about all the biomarkers and how to ensure you get tested.

HAI (hepatic artery infusion) pump therapy is a potential treatment option for patients diagnosed with stage IV colorectal cancer which has metastasized (spread) to the liver.

Colorectal cancer is the third most frequently diagnosed cancer in the United States among men and women, and when men and women are combined, it is the #2 cause of cancer death.

Ultimately, over 50% of patients diagnosed with CRC will develop liver metastasis.

Traditional chemotherapy is “systemic,” which means it is administered and distributed throughout the entire body. HAI pump therapy is different in that it delivers chemotherapy directly to the liver, providing up to 400 times greater drug concentration where it is needed. It accomplishes this by delivering chemotherapy to the hepatic artery, which supplies blood to the liver.

How HAI Pump Placement Works

HAI pump surgery is a minor procedure that places the port in the abdomen just below the skin, somewhat like a port that is used for traditional chemotherapy. The pump is then filled with the drug being used to treat the tumors in the liver, slowly delivering medication at a constant rate.  

The pump is powered by body heat and refilled every two weeks during active treatment. The pump can be filled with an inactive fluid during treatment breaks. 

Benefits of HAI Pump Therapy for Liver Metastases

For patients with mets to the liver that cannot be surgically removed, HAI pump therapy may be an option to help prevent the tumors from growing, and in some cases even shrinking them, which may prolong survival and help them become a surgery candidate.  

For patients that have had their tumors surgically removed, HAI therapy may help prevent new tumors from forming and may prolong survival. 

Possible Side Effects of HAI Pump Therapy

No therapy is without side effects, including HAI therapy. However, patients generally report fewer chemotherapy related side effects when compared to traditional systemic chemotherapy. Possible side effects include: 

• Nausea 

• Vomiting 

• Diarrhea 

• Elevated liver enzymes 

It is important to follow all instructions given by your provider. While you can remain active with an HAI pump, you should rough physical activity that may damage the pump. You should also avoid scuba diving, and be careful to avoid activites that may increase your body temperature, such as using a hot tub, during active treatment, as this can alter the medication flow rate. 

How to Receive HAI Pump Chemotherapy

HAI therapy is administered by a physician specially trained to do so. There are several centers across the U.S. now offering this treatment option. After placement of the pump, the pump will be managed by the provider, who will refill the pump and decide on a course of treatment. 

Success Stories with HAI Pump Therapy

“My experience with the Hepatic Artery Infusion (HAI) pump was truly life-changing—and, without question, life-saving. From the moment it was implanted, I not only remained cancer-free, but I was able to fully live my life in ways I never imagined possible during cancer treatment. I continued running, working out, and staying active. One of the greatest advantages of the HAI pump was the absence of the debilitating systemic side effects I experienced with traditional chemotherapy. The treatment targeted my liver directly, which meant my other organs were spared from the harmful effects of chemotherapy. That fact proved critical to my survival. A year later, I unexpectedly went into liver failure due to biliary inflammation. Because the rest of my body had been spared from chemo-related damage, I was strong and healthy enough to undergo a living donor liver transplant. The HAI pump quite literally became the bridge that kept me cancer-free and in peak enough condition to qualify for groundbreaking transplant research at Cleveland Clinic. Now, nearly nine years later, I have no lingering complications from the pump or the treatment, aside from a small hernia that will be repaired soon. The HAI pump didn’t just save my life—it gave me back my life while I was fighting for it.”

Carole Motycka, Stage IV Survivor

Next steps

If you have colorectal cancer with metastasis to the liver, HAI therapy may be an available treatment option. Talk to your oncologist to learn more.  

Fight Colorectal Cancer has received funding from Intera Oncology (now part of Boston Scientific), the producers of HAI Therapy, in the form of unrestricted educational grants. We maintain ultimate authority over website content and the content written in this article. 

Ever since the dawn of colonoscopy, nearly all patients have been advised to go on a clear liquid diet the day before a procedure and to avoid any solid foods. But new multi-society guidance suggests another way.

We highlighted this idea several years ago when Dr. Jeff Scott from Happy Colon Foods presented a way for colonoscopy prep to “not suck,” where he showed studies indicating a low-residue diet would not only make “prep day” more comfortable, but it would result in a sufficient colon cleanse. After undergoing a thorough review, the U.S. Multi-Society Task Force on Colorectal Cancer updated their official recommendations for bowel prep prior to a colonoscopy. These were published in the March 5, 2025 issue of Gastroenterology.

When it comes to what you can eat the day before a colonoscopy, the updated recommendations state:

“We recommend limiting dietary restrictions to the day before a colonoscopy, relying on either clear liquids or low-fiber/low-residue diets for the early and midday meals.”

This is a major change for patients who struggle to fast and follow the clear liquid diet the day before a colonoscopy.

“We know that a huge barrier to completing colonoscopy is the prep,” said Swati G. Patel MD, MS, CGAF. “If we can make the process just a tad easier, it can go a long way towards improving screening rates.”

Clear liquid diet for colonoscopy prep

The updated recommendations do not eliminate the suggestion of following a clear liquid diet prior to a colonoscopy. The following would fall under this category:

• Water
• Coffee and Tea (no cream or sugar)
• Broth
• Apple juice or white grape juice (nothing with pulp)
• Ice slushies and Popsicles (no red/orange/blue dyes)
• Jello (no red/orange/blue dyes)
• Gatorade, PowerAde and other electrolyte drinks (avoid red/orange/blue dyes)
• Sparkling water
• Sprite, 7-Up, Ginger Ale and other sodas

And for those who are wondering if Diet Coke counts as a clear liquid, the answer is YES!

Low fiber diet for colonoscopy prep

But now, you may be able to eat a low-fiber breakfast and lunch the day before your colonoscopy. It will be important to err on the safe side. If you have any questions about if a food is low fiber or not, ask your doctor or avoid eating it, and choose an option you’re certain is on the list.

What foods are part of a low fiber diet? Anything with whole grains, nuts, seeds, and skins are NOT low fiber. Generally, canned or cooked foods are allowed, but not raw or dried fruits or veggies.

Here’s a quick list of what you could safely eat for breakfast and lunch (before 2pm) on the day before a colonoscopy:

• Eggs, chicken, or fish
• Milk, cheese, and yogurt
• Bananas, applesauce, or other ripe, seedless fruits
• Strained juices (no pulp!)
• White bread, white rice, saltine crackers, Ritz crackers
• Cream of Wheat or grits
• Rice or puffed cereals, or corn flakes
• Cooked vegetables without seeds
• Avocado
• Most sauces and condiments are OK (except the fruit jellies with seeds)

How does a low fiber diet help with colonoscopy prep?

Some people have a hard time fasting the day before a colonoscopy, and a low-fiber diet may help curb hunger and make prep night more tolerable.

Research shows that when comparing patients who followed a clear liquid diet to those who ate a low fiber diet on the day before a colonoscopy, both patient groups had sufficient preps that meant the doctors could perform the colonoscopy.

However: It was critical for the patients to follow all prep instructions, and to take all the prep product.

“Our goal is to prescribe a prep that is the least painful for our patients, but still achieves a high-quality cleanse so we can get a good look,” Dr. Patel said. “We often have to customize the prep for patients. It is important to share your full medical history and medication list with your colonoscopy doctor’s office. There are certain medical conditions and medications that slow down the bowels. In these scenarios, eating solids prior to your procedure may not be a good idea and you may even need a more aggressive prep. Based on your specific situation, the doctor’s office will recommend a prep that is compatible with your medical issues and has the highest chance of producing a good quality prep. In the end, the most important thing is to follow the instructions to minimize the risk of missing a polyp, or having to repeat the colonoscopy due to suboptimal prep.”

Colonoscopy diet is very important

A colonoscopy prep diet is very important, as it’s part of what makes a colonoscopy lifesaving. While this guidance does ease up on the clear liquid diet the day before a colonoscopy, it’s important to work closely with your doctor and eat mindfully and cautiously. When in doubt, stick to clear liquids so your colon will be as clean as possible.

Why?

A cleansed colon will give your gastroenterologist a good look, ensuring nothing is missed. It will also help you avoid an incomplete prep, which leads to needing to redo prep night, reschedule your procedure, and possibly pay more.read our experts tips

The DEA is warning consumers about counterfeit drugs, including fake Adderall advertised on the Internet.

The fake pills are not made by Teva Pharmaceuticals or other legitimate pharmaceutical companies, contain none of the active Adderall ingredients, and instead have ingredients that may be dangerous, such as fentanyl or methamphetamine.

Adderall is a stimulant approved by the FDA to treat attention deficit disorder and narcolepsy but is occasionally prescribed off-label for cancer-related fatigue.

If something looks “off” about your medication or its packaging, you may be in possession of counterfeit drugs. Be on the lookout for misspellings on the packaging or differences in pill markings, shape, or color from what you are familiar with.

Resources for Keeping Yourself Safe from Counterfeit Drugs

The FDA provides information and resources on how to keep yourself safe from counterfeit drugs, and what to do if you suspect the drugs you have are fake. You can also contact the FDA’s Office of Criminal Investigations (OCI) at 800-551-3989 if you believe you have received counterfeit Adderall or other drugs.

Unpacking Laxatives

Patients who have purchased counterfeit Adderall should not take it and talk to their doctors about obtaining the right medicine. With so many drugs in short supply right now, the FDA warns patients to be particularly careful when buying medicine on the Internet.

The Bottom Line About Fake Adderall

Most patients think the prep was specifically chosen for them by their doctor. The actual truth is most patient’s preps are chosen by the scheduler from a list of OTC and prescription preps OK’d by the doctor. Schedulers are either medical assistants or nurses that are typically office-based. Unfortunately, because they are primarily in the office, they do not get much exposure to the actual colonoscopy experience. They also do not get to hear the patient’s colonoscopy prep stories, and if they had any significant difficulties. Because of these factors, schedulers may choose colon preps based on some misperceptions.

One of the most common misperceptions is the cost of the prep. Rightfully so, many schedulers tend to be very cost-conscious and frequently use that to choose preps. Schedulers are commonly informed by industry reps that a prescription prep is “covered” by insurance. This can be easily misunderstood to mean the prep has “no cost” to the patient. What this means is insurance pays a portion of the cost, but the patients typically have a copay, and it is almost impossible to know what that amount is until the patient is at the pharmacy. In a quality improvement project for our office, we asked 500 patients with insurance what was their copay, or out-of-pocket expense, for their prescription prep. We found that patient copays ranged widely from $0-$165, with an average copay of $72 for their prescription prep. So “covered” does not mean free.

When you think of colorectal cancer, you most likely imagine a patient who is older, as the average diagnosis age is 68 for men and 72 for women. Currently, the recommended age to begin screening for average risk individuals is 45. However, the reality is that people under the age of 45 can develop colorectal cancer as well.

There is a lesser-known risk factor for colorectal cancer – toxic exposure – that may contribute to cases of colorectal cancer.

For most of the past century, industrial workers and military members regularly came into contact with carcinogenic agents, or agents that are known to cause cancer, such as asbestos, polyfluoroalkyl substance (PFAS), benzene, Agent Orange, dioxins, lead, burn pits, and polychlorinated biphenyl (PCBs).

If you were exposed to one of these toxic agents, having a colonoscopy or other screening method is the only way to prevent or timely diagnose colorectal cancer.

Colorectal Cancers Among Veterans Due To Toxic Environments

During the past century, members of the military frequently were exposed to carcinogenic agents. Over the course of the Vietnam War, military members on active duty were exposed to Agent Orange, a dangerous herbicide mixture containing dangerous chemicals known as dioxins that was sprayed over forests and foliage. Another important toxic agent is PFAS, which is a group of chemicals that have been released into the environment of military bases since 1966 due to firefighters and trainees using the fire suppressant known as Aqueous Film Forming Foams. PFAS are extremely toxic and currently contaminate over 700 military bases in the country.

Numerous veterans who spent time on duty in Afghanistan developed colorectal cancer, which in part may be due to frequently inhaling the acrid fumes released by burn pits. Electronics, food wrappers, metals, and soiled uniforms were just some of the items that were set on fire using jet fuel. Abundantly present in the military, asbestos was another toxic agent endangering the health of military members. It could be found nearly anywhere in the military, from ships to barracks. There were over 300 asbestos products aboard every U.S. Navy ship. Everyone who was aboard U.S. Navy ships unavoidably inhaled and ingested toxic fibers.

Occupational Exposure in Colorectal Cancer

By virtue of the many convenient properties asbestos has, it should come as no surprise that asbestos was also present in industrial settings. Since the early 1920s, major companies that used asbestos had been striving to hide the negative health consequences of exposure from workers, conspiring to keep employing asbestos, oftentimes putting financial profit over the health of employees. As a result, millions of employees from over 70 occupational groups were exposed to asbestos to a certain extent. The workers who were regularly exposed to high airborne concentrations of asbestos include construction workers, shipyard workers, and textile mill workers.

Besides asbestos, there were many other toxic agents people working in industrial settings were exposed to, such as PCBs. Until 1976, when they were banned, PCBs had been manufactured in the U.S. on a large scale and used as insulation, coolants, and lubricants in transformers, electrical appliances, capacitors, and old fluorescent lighting fixtures. People who were responsible for manufacturing these products were inevitably exposed, which increased their risk of developing colorectal cancer.

Medical Errors Can Delay the Diagnosis of Colorectal Cancer

Because a significant number of veterans and former industrial workers develop colorectal cancer before reaching the recommended screening age of 45, medical specialists are inclined to overlook the possibility that these patients could, in fact, suffer from this disease. For instance, a veteran with colorectal cancer may initially be misdiagnosed with irritable bowel syndrome, as their symptoms, including blood in the stool and abdominal pain, are consistent and common with both health problems.

What is unsettling is that for years the patient could go about their life without knowing that they actually have cancer. Usually, in people who are considered too young to have colorectal cancer by the medical community, the disease is found accidentally, such as during a CT or MRI scan. In addition to irritable bowel syndrome, the most common misdiagnoses for colorectal cancer include diverticulitis, ulcerative colitis, and hemorrhoids. The most frequent medical errors leading to misdiagnoses in patients with colorectal cancer are the following:

failure to order a blood stool test

failure to offer a routine colorectal cancer screening

failing to identify and remove a polyp at colonoscopy

failing to visualize the entire colon during a colonoscopyfailure to adequately follow up on the results of a colonoscopy

failure to recommend a colonoscopy to a patient with symptoms

In most cases, colorectal cancer grows slowly over a period of several years, usually beginning as small benign growths, medically known as polyps. Removing a polyp early, before it becomes malignant, prevents it from developing into cancer. This is the reason why colonoscopy helps prevent the development of colorectal cancer.

Additionally, colonoscopy can lead to diagnosing colorectal cancer in the early stages before it has spread to other tissues and organs. The difference in prognosis when cancer is detected early versus when it is found in advanced stages is tremendous – the five-year survival rate is 90% in the former case, whereas in late stage colorectal cancer survival rate is lower than 14%.

It is also important to support additional colorectal cancer research to develop improved screening techniques and better treatment options. The Department of Defense conducts medical research through its Congressionally Directed Medical Research Program. Fight Colorectal Cancer is working with champions in Congress to create a Colorectal Cancer Research Program.

For over 25 years, Environmental Litigation Group, P.C., has been assisting people whose health was affected by toxic exposure with recovering compensation from the responsible companies. The law firm has recently launched the Heroes and Sacrifices campaign, through which you can request a gift basket if you are a former industrial worker or a veteran.