Purpose of review <p>The severe long-term toxicities of standard therapy for nasopharyngeal carcinoma underscore the need for treatment de-escalation. This review summarizes the rationale and evolving approaches to reduce treatment intensity while maintaining efficacy, with the goal of balancing survival outcomes and quality of life.</p> Recent findings <p>De-escalation strategies primarily focus on two domains: (1) radiotherapy optimization through target volume reduction, response-adapted dose de-escalation, and advanced techniques for organ preservation; (2) systemic therapy adjustments, including omitting concurrent chemotherapy in low-risk patients and exploring alternative or reduced-intensity cisplatin regimens. Emerging evidence suggests these approaches can significantly lessen toxicities such as hearing loss and xerostomia without compromising survival.</p> Summary <p>De-escalation represents a promising paradigm for personalizing treatment in nasopharyngeal carcinoma. However, its implementation is hindered by the absence of standardized patient selection criteria. Future research should prioritize prospective multicenter trials to establish validated protocols and achieve personalized, less toxic therapy.</p>