The study by Yousef and El-mashad 1 describes a randomized trial demonstrating effectiveness of intravenous methylprednisolone for the prophylaxis of pain flare after standard-course radiation therapy (RT) for the treatment of painful spinal metastases. Pain flares have been described after the administration of both radiopharmaceuticals 2 and external beam radiation therapy for the treatment of bone metastases and may be more common after single-fraction palliative radiation treatment. 3 Interestingly, in the present study, pain relief in the treatment arm persisted for the entire month of follow-up, not just during the few days immediately after RT, when pain flares usually occur. In current oncology practice in the U.S., dexamethasone is generally the corticosteroid of choice for cancer pain given its mineralocorticoid-sparing effects and availability by the oral route. It is unclear if practitioners and patients would be willing to substitute a two-hour intravenous infusion for a once-daily oral medication. Furthermore, it is important to note that the dose of methylprednisolone in this study was quite high (a 5 mg/kg dose in a 70 kg patient converts to a dexamethasone dose of 60 mg/day). This is much higher than typical doses for pain management and is significantly higher than the dose used in a previous phase II study of prophylactic dexamethasone for pain flares. 4 on completing a randomized trial in palliative radiation oncologythatraisesimportantclinicalissues.Theresults of this study also illustrate the importance of adequate pain control in enhancing important quality-of-life aspects such as ambulation and mood. Future research could build on this work by investigating whether dexamethasone is comparable with methylprednisolone for pain flare prophylaxis and working to establish the optimal steroid dose for the prevention of pain flares in patients receiving palliative radiation for bone metastases.