Comprehensive genomic profiling in solid tumours: Navigating promise, challenges, and pathways to clinical...

The advent of high-throughput technologies has significantly enhanced our understanding of cancer biology. Genomic profiling methods, now widely and commercially available, have shifted the focus from traditional histology-based classifications and drug development toward the identification of specific molecular alterations, many of which may predict response or resistance to an expanding arsenal of targeted agents and immunotherapies. This paradigm shift has laid the foundation for precision oncology, an approach in which treatments are tailored to actionable molecular targets, sometimes regardless of tumour site of origin, as exemplified by tissue-agnostic strategies. This new framework has subsequently reshaped the design of clinical trials, favouring innovative approaches such as trials that enroll patients with different tumour types sharing common genomic features. These trials often incorporate adaptive cohort designs aligned with the availability of novel drugs, allowing for the early assessment of their antitumour activity across multiple tumour types. As a result, significant regulatory milestones have been achieved, with nine anticancer agents having received tissue-agnostic approvals as of 2025. Despite the achievements of precision oncology, several challenges remain to be addressed. Tumour heterogeneity, the need for robust efficacy endpoints, and the requirement for confirmatory evidence, among other factors, continue to limit the widespread implementation of precision oncology and pose regulatory hurdles. This review discusses key trials supporting the clinical role of comprehensive genomic profiling in solid tumours, examines the evidence behind tissue-agnostic drug approvals, and highlights both the progress achieved and the remaining barriers to fully integrating precision oncology into routine clinical care.