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PURPOSE: Rural-residing cancer patients often do not participate in clinical trials. Many patients misunderstand cancer clinical trials and their rights as participant. The purpose of this study is to modify a previously developed cancer clinical trials decision aid (DA), incorporating the unique needs of rural populations and test its impact on knowledge and decision outcomes. METHODS: The study was conducted in two phases. Phase I recruited 15 rural-residing cancer survivors in a qualitative usability study. Participants navigated the original DA and provided feedback regarding usability and implementation in rural settings. Phase II recruited 31 newly-diagnosed rural-residing cancer patients. Patients completed a survey before and after using the revised DA, R-CHOICES. Primary outcomes included decisional conflict, decision self-efficacy, knowledge, communication self-efficacy, attitudes towards and willingness to consider joining a trial. FINDINGS: In Phase I, the DA was viewed positively by rural-residing cancer survivors. Participants provided important feedback about factors rural-residing patients consider when thinking about trial participation. In Phase II, after using R-CHOICES, participants had higher certainty about their choice (mean post-test = 3.10 v. pre-test = 2.67; P = 0.025) and higher trial knowledge (mean percent correct at post-test = 73.58 v. pre-test = 57.77; P < 0.001). There was no significant change in decision self-efficacy, communication self-efficacy, attitudes towards or willingness to join trials. CONCLUSION: The R-CHOICES improved rural-residing patients’ knowledge of cancer clinical trials and reduced conflict about making a trial decision. More research is needed on ways to further support decisions about trial participation among this population.