Nasopharyngeal carcinoma (NPC) is especially responsive to both chemotherapy and radiotherapy. It also exhibits a strong and disappointing tendency to metastasize to both regional lymph nodes and distant sites. Distant relapse in NPC is generally fatal and usually relates to advanced-stage presentation, and especially extensive regional lymph node involvement, but also to the presence of the less-differentiated histologic patterns of disease that predominate in the endemic-disease areas of the world. Recent improvements in survival are likely attributable to the adoption of concurrent chemotherapy as a predominant approach, although distant metastases remain as a significant cause of death. Survival improvements probably do not always relate to the use of chemotherapy. Thus contemporary series enjoy a greater advantage compared with historical results because of advances in tumor imaging and radiotherapy delivery. It is impossible to assess the impact of these parameters on previous trial results, and it remains plausible that outcomes may still be significantly influenced by imprecise radiotherapy targeting. The randomized trials in the English literature designed to address the impact of chemotherapy on the survival of NPC patients are discussed. Potential causes of inconsistencies among trials are outlined, and the results of the only individual patient data meta-analysis are summarized. The discussion concludes with some commentary concerning newer strategies for the management of NPC to address the problem of distant metastases.