The goal of this clinical trial is to see if telephone support programs help patients and their family caregivers adjust to advanced gastrointestinal cancer. A new telephone counseling program that involves practicing strategies for managing stress and symptoms will be compared to a telephone program involving education on quality-of-life issues and psychosocial support. The main questions it aims to answer are:

Does our telephone counseling program lower the negative impact of patients' fatigue on their activities, emotions, and thinking abilities compared to a telephone program involving education and support? Does our telephone counseling program lower family caregivers' feelings of burden compared to a telephone program involving education and support?

Participants in both study conditions will:

Complete 6 weekly telephone sessions of counseling or education/support Complete a telephone booster session Complete 3 telephone interviews over about 5 months

This trial tests the effects of telephone-delivered acceptance and commitment therapy (ACT) on patient fatigue interference with functioning and family caregiver burden in advanced gastrointestinal (GI) cancer (Aim 1) as well as secondary outcomes (Aim 2). This trial also examines increases in psychological flexibility as a hypothesized mediator of ACT's effects on patient fatigue interference and caregiver burden (Aim 3). Finally, two core aspects of psychological flexibility (i.e., mindfulness/acceptance and commitment/behavior change processes) are examined as exploratory mediators of ACT's effects on patient fatigue interference and caregiver burden (Aim 4). The investigators will recruit advanced GI cancer patients and caregivers from Indiana University Health, Eskenazi Health, MD Anderson Cancer Center, and Northwestern University hospitals. Potentially eligible patients will be mailed a study introductory letter along with a consent form. The letter will have a number to call if they do not wish to be contacted further. A research assistant will call all prospective participants who do not opt out approximately 1 to 2 weeks after the letter is mailed. The research assistant will describe the study as outlined in the consent form and answer any questions. Then the research assistant will administer an eligibility screening to those who consent to participate. With the patient's permission, the primary family caregiver will also be mailed a consent form and contacted via phone to screen for eligibility and obtain consent. Consenting patients and caregivers will complete a 35-minute individual phone assessment at baseline.

Following baseline assessments, patient-caregiver dyads (N = 244) will be randomly assigned in equal numbers to ACT or education/support using a stratified block randomization scheme to balance the groups by patient age (<65 vs. >=65 years) and performance status (patient-reported Eastern Cooperative Oncology Group [ECOG] scores 0 or 1 vs. 2). Dyads in both groups will complete six weekly 50-minute telephone sessions with the first session occurring one week after baseline. Blind interviewers will assess outcomes during 30-minute individual phone assessments at 2 weeks and 3 months post-intervention. Dyads in both conditions will also complete a 30-minute booster phone session one month after the 2-week follow-up. During the booster session, ACT therapists will reinforce and address any barriers to skill practice, and education/support therapists will review key medical center and community resources.

Patient Inclusion Criteria:

• Patient is at least 3 weeks post-diagnosis of unresectable stage III or stage IV gastrointestinal cancer (i.e., ampullary, anal, appendix, bile duct, colon, esophageal, gallbladder, liver, pancreatic, rectal, small intestine, or stomach cancer) and is receiving cancer care at one of the study sites.
• Patient is at least 18 years of age.
• Patient can speak and read English.
• Patient has an eligible, consenting family caregiver (see criteria below).
• Patient has moderate to severe fatigue interference with functioning.

Patient Exclusion Criteria:

• Patient shows significant psychiatric or cognitive impairment that would preclude providing informed consent and study participation.
• Patient reports being able to do little activity on a functional status measure.
• Patient is receiving hospice care at screening.
• Patient does not have working phone service.
• Patient has hearing impairment that precludes participation.
• Patient participated in the pilot trial testing the same intervention.

Caregiver Inclusion Criteria:

• Family caregiver identified by a gastrointestinal cancer patient who meets the eligibility criteria.
• Caregiver has significant caregiving burden.
• Caregiver lives with the patient or has visited the patient in-person at least twice a week for the past month.
• Caregiver is at least 18 years of age.
• Caregiver can speak and read English.

Caregiver Exclusion Criteria:

• Caregiver shows significant psychiatric or cognitive impairment that would preclude providing informed consent and study participation.
• Caregiver does not have working phone service.
• Caregiver has hearing impairment that precludes participation.
• Patient declines study participation.

The dataset to be shared will include individual-level baseline, procedural-based (intervention session attendance, homework completion), and outcome data for approximately 244 patients and 244 family caregivers. Data will be collected from self-report surveys and the Electronic Medical Record (EMR). Data from scored assessments (e.g., psychosocial questionnaires) will include both raw data elements (e.g., individual item responses) and summary information (e.g., total scores) where feasible. To protect the privacy of study participants, the investigators will develop a plan for de-identification of this dataset, which will address participant identifiers, dates, variables that are administrative or sensitive in nature, unedited verbatim responses that are stored as text data, and variables with low frequencies for some values.

The research community will have access to the data no later than the time of an associated publication or end of the performance period, whichever is first.

Data will be findable for the research community through the Harvard Dataverse. A data digital object identifier (DOI) generated by the Harvard Dataverse will be referenced in all publications to allow the research community easy access to the exact data used in the publication. Access to the data will be restricted to qualified researchers to prevent misuse, misinterpretation, and confusion.

Research staff will be blind to study condition when administering assessments to participants via phone.