Abstract
Precision oncology is witnessing an increasing number of molecular targets fueled by the continuous improvement of cancer genomics and drug development. Tumor genomic profiling is nowadays (August 2025) part of routine cancer patient care, guiding therapeutic decisions day by day. Nevertheless, implementing and distilling the increasing number of potential gene targets and possible precision drugs into therapeutically relevant actions is a challenge. The availability of prescreening programs for clinical trials has expanded the description of the genomic landscape of gastrointestinal tumors. The selection of the genomic test to use in each clinical situation, the correct interpretation of the results, and ensuring clinically meaningful implications in the context of diverse geographical drug accessibility, economic cost, and access to clinical trials are daily challenges of personalized medicine. In this context, well-established negative predictive biomarkers, such as extended RAS extended mutations for anti-EGFR therapy in colorectal cancer, and positive predictive biomarkers, such as MSI status, BRAF p.V600E hotspot mutation, ERBB2 amplification, or even NTRK1, NTRK2, NTRK3, RET, and NRG1 fusions across gastrointestinal cancers, are mandatory to provide tailored clinical care, improve patient selection for treatment and clinical trials, maximize therapeutic benefit, and minimize unnecessary toxicity. In this review, we provide an updated overview of actionable genomic alterations in GI cancers and discuss their implications for clinical decision making.