Should dexamethasone be standard in the prophylaxis of pain flare after palliative radiotherapy for bone metastases?-a debate

Pain flare is a well-recognized side-effect of palliative radiotherapy for the treatment of painful bone metastases, with recent randomized data showing incidence rates up to 35%. The impact of pain flare has been associated with worsening immobility, anxiety, depression and quality of life. The use of dexamethasone has recently been supported as an effective option in reducing radiation-induced pain flare based on the NCIC Clinical Trials Group (NCIC CTG) Symptom Control 23 (SC. 23) randomized double-blind placebo-controlled trial. Despite this, conflicting opinions exist, and standard clinical use of dexamethasone to prevent pain flare continues to be debated among clinicians. Given this controversy, two sides of the debate are presented. Although consensus has not been achieved, the choice to use dexamethasone in the prophylactic setting to reduce pain flare incidence should be a shared decision between the oncologist and patient. Factors including symptom burden, comorbidities, performance status, quality of life and radiation dose and fractionation should be taken into account on an individualized level.