Background: Bone metastases (BM) are a painful complication of advanced 
malignancies, significantly reducing patients' quality of life. Radiotherapy (RT) 
is a cornerstone in the palliative treatment of BM, with different fractionation 
schedules used globally. This study compared two multi-fractionated RT 
regimens -30 Gy/10 and 20 Gy/5 fractions- focusing on pain control, re-
irradiation rates, relapse, toxicity, and overall survival (OS). 
Methods: This prospective, randomized controlled trial was conducted at the 
South Egypt Cancer Institute, Assiut University, including 100 patients with 
confirmed painful BM. Patients received either 30 Gy/10 fractions (n=50) or 20 
Gy/5 fractions (n=50). Pain relief was assessed using the Visual Analogue Scale 
at 1- and 3-months post-treatment. Re-irradiation rates, relapse, acute toxicity, 
pathological fractures, spinal cord compression, and 1-year OS were evaluated. 
Results: At 1 month, the overall response rate was 88% in the 30 Gy group and 
82% in the 20 Gy group (p=0.9), with similar results at 3 months (76% vs. 72%, 
p=0.991). Although both regimens provided effective pain control, patients in 
the 30 Gy group had a lower rate of pain progression (1.6% vs. 6.5%) and re-
irradiation (6% vs. 12%) compared to the 20 Gy group. Acute toxicity was 
significantly higher in the 30 Gy group, with 25% experiencing Grade 1-2 
toxicity compared to 5% in the 20 Gy group (p<0.0001). Skin reactions and 
fatigue were the most common side effects. Pathological fractures and spinal 
cord compression were observed in 4% and 6% of patients in the 20 Gy group, 
compared to 2% in both categories in the 30 Gy group. 1-year OS was 
comparable between groups (35% for 20 Gy and 39% for 30 Gy, p=0.527). 
Conclusion: Both regimens offered high rates of pain relief, but the 30 Gy 
regimen provided more durable pain control, reflected in lower re-irradiation 
rates and pain progression. However, this came at the cost of higher acute 
toxicity. The 20 Gy might be more appropriate for patients with a lower 
performance status or in high-volume centers where shorter treatment times and 
fewer side effects were prioritized.