Background: Among the growing older adult U.S. population, under-treated cancer pain is a major public health concern. Those living in rural areas are even more vulnerable due to less access to care, patients’ concerns around the over-use of pain medication, and patients’ preferences for non-pharmacological interventions. There is a clear need for interventions designed to improve pain management among this vulnerable population. Methods: In this study, older adults with cancer (age 65+ years) were enrolled in an open arm trial in rural Tennessee to test feasibility, acceptability, and potential efficacy of a previously developed intervention, Ca-HELP, to improve pain communication with one’s oncologist. Prior to the trial, the original Ca-HELP intervention was adapted for use among older adults in rural settings. Feasibility was examined through accrual and intervention completion rates. Acceptability was measured through single-item questions assessing helpfulness, difficulty, and satisfaction with the intervention. Intervention efficacy was assessed using mean score differences from pre- and post-intervention assessments of pain self-management, self-efficacy for communicating with physicians about pain severity, pain severity, and misconceptions about pain. Mean score differences were analyzed using one-tailed paired samples t-tests, with an alpha level = 0.05. Results: A total of n = 30 patients were enrolled in this trial, adequately powering this trial (0.85) to detect moderate effect size differences. Participants were 56.7% female, predominately white (80.0%), less educated (53.3% less than high school), and lower income (50.0% household income less than $21,000). Fidelity rates of 90% for communication consistency (pacing, volume, introduction to purpose of intervention) and 100% for delivery of intervention components were observed. This intervention was highly feasible, with a 100% accrual rate and 100% intervention completion rate. Regarding acceptability, all patients (n = 30) rated the intervention as helpful, with the majority rating it as “very helpful” (n = 24, 80.0%). Most patients rated the intervention as “not at all difficult” (90.0%), enjoyed participating in the intervention (70.0%), and were “very satisfied” with the intervention (83.3%). Pre/post changes in outcomes indicated significant improvements in pain self-management and self-efficacy for communicating with physicians about pain severity, as well as significant reductions in pain severity and pain misconceptions (all p< .05). Conclusions: Results of this study indicate the adapted version of Ca-HELP was feasible, acceptable, and had potential efficacy for improving pain related outcome measures among older adults with cancer in a rural setting. Clinical trial information: NCT04262232.