Precision medicine is fundamentally transforming cancer treatment by enabling personalized therapies based on genomic and molecular profiling, moving away from traditional approaches that rely solely on tumor histology. Within this evolving landscape, precision medicine oncology pharmacists have emerged as indispensable members of multidisciplinary care teams, contributing specialized expertise in targeted therapy selection, patient access navigation, and toxicity management.
Molecular Tumor Boards and Targeted Therapy Matching
At the core of precision oncology lies the identification of actionable genomic alterations and the development of individualized treatment plans. Molecular tumor boards (MTBs) serve as the central hub for this process, bringing together pharmacists, physicians, advanced practice providers, nurses, genetic counselors, and scientists to examine genetic sequencing and molecular profiling data.
Pharmacists contribute to MTBs by analyzing next-generation sequencing reports and assisting in matching detected alterations with guideline-recommended therapies, novel drug combinations, or clinical trials. They assess the appropriateness of targeted agents based on factors including drug metabolism, potential resistance mechanisms, coexisting comorbidities, and drug interactions.
When evaluating novel drug combinations, pharmacists play a critical role in assessing potential overlapping toxicities. As much of the toxicity profile of novel drug combinations remains undefined in current literature, pharmacists lead discussions regarding potential toxicities and recommend appropriate monitoring strategies, utilizing their pharmacologic expertise and clinical experience.
The precision medicine oncology pharmacist also serves as co-moderator of new FDA drug approvals for MTBs. When targeted treatments receive FDA approval, pharmacists present critical information regarding drug targets, biomarkers, efficacy results from landmark trials, and key safety monitoring requirements, while informing teams of anticipated access or reimbursement barriers.
Overcoming Medication Access Barriers
Patient access to matched targeted therapy remains a significant implementation barrier in precision oncology. Exorbitant drug prices, insurance restrictions, complex reimbursement policies, and restrictive manufacturer patient assistance programs often delay treatment initiation for patients with aggressive cancers.
Precision medicine oncology pharmacists lead efforts to overcome these financial barriers by facilitating prior authorizations and appeals, authoring letters of medical necessity, and supporting patient access to financial assistance programs. Working with specialized medication access pharmacy technicians, they streamline comprehensive prior authorization requests and assist providers in submitting insurance appeals with clinical justification and supporting documentation from genomic reports and published literature.
When appeals are denied due to insurance restrictions on off-label use of targeted agents, patient assistance programs become the final option for medication access. Pharmacists identify available manufacturer programs, assist patients with application completion, and communicate with field reimbursement managers to overcome barriers to novel drug combination access.
Drug repositories and compassionate use programs provide additional unique routes for medication access. Pharmacists promote donations of factory-sealed unused medications from patients who have progressed on therapy to facility repositories, helping remove hazardous medications from patients' homes while providing access to patients facing insurance delays or other barriers.
Comprehensive Patient Education and Monitoring
Before initiating any new oral anticancer medication, pharmacists conduct comprehensive medication histories with patients, reviewing current medications for potential drug interactions. When interactions are identified, pharmacists recommend avoidance or mitigation strategies, including changing supportive care medications, adjusting doses, or recommending specific administration instructions.
Patient education sessions cover medication dosing and administration, safe handling of medications and bodily fluids, notable food and drug interactions, storage considerations, and significant adverse effects monitoring. Take-home teaching documents provide patients with written copies of all discussed information.
The precision medicine approach necessitates diligent monitoring of adverse effects, particularly with novel drug combinations. Pharmacists employ their pharmacologic knowledge to assess overlapping toxicities within combinations and ensure appropriate monitoring implementation. They complete proactive monitoring and toxicity assessments between provider appointments and collaborate with providers during clinic visits.
Current Implementation Challenges
Despite rapid innovation in precision medicine, pharmacist involvement remains underutilized. A survey presented at the 2025 Hematology/Oncology Pharmacy Association Annual Meeting found that up to 70% of pharmacists were unaware of institutional precision medicine initiatives. Barriers cited included lack of training, insufficient institutional support, time constraints, and unfamiliarity with genomic technologies.
Mya Tran, PharmD, BCOP, a precision oncology clinical pharmacist at Indiana University Health Simon Cancer Center, noted the overwhelming complexity of precision medicine with constantly evolving molecular data. "It's really hard to take that additional responsibility to learn a new skill set, like interpret genomic data and know how to apply that in practice—it's really tough," Tran said during the 2025 Oncology Pharmacists Connect meeting.
Precision Oncology Testing Strategies
Precision oncology relies on three major testing strategies: somatic tumor testing, germline testing, and pharmacogenomic assessments. The 2022 American Society of Clinical Oncology guidelines recommend upfront comprehensive somatic genomic testing using multigene panel assays that include at least 50 genes for most patients with advanced or metastatic solid tumors.
These broad panels enable detection of rare and emerging biomarkers such as high tumor mutational burden, EGFR exon 20 insertions, or gene fusions involving ALK, ROS1, or NTRK that can guide therapy selection or clinical trial enrollment.
Real-World Impact Through Case Examples
The clinical impact of precision medicine pharmacist involvement is demonstrated through patient outcomes. Tran shared a case of a 45-year-old male with newly diagnosed metastatic non-small cell lung cancer who initially tested negative on NGS at an outside hospital and was started on immunotherapy plus chemotherapy with rapid disease progression.
A liquid biopsy conducted at IU revealed a rare EGFR-RAD51 fusion at 0.4% variant allele frequency. Given limited options, the team initiated osimertinib off-label, resulting in dramatic patient response with regained mobility and return to full-time work and parenting. "By June 25 of 2022, he was doing great," Tran said. "His baby boy's almost 3 years old now. He is back to running and working full time."
Future Directions and Institutional Models
To address implementation barriers, comprehensive precision genomics programs like IU's model include centralized teams with oncologists, pharmacists, molecular pathologists, variant scientists, and genetic counselors. The workflow encompasses biopsy coordination, NGS testing, tumor board-based variant interpretation, pharmacist-led documentation and patient counseling, and trial referral coordination.
In this model, pharmacists function similarly to antimicrobial stewardship experts, interpreting molecular data and selecting drugs in collaboration with oncologists. As Tran concluded, "As a pharmacist, I think we are built to be a part of precision medicine. I think this is a very exciting time. My vision in the next couple of years is going to be more pharmacists who participate in different precision medicine initiatives."
