Background <p>Comprehensive genomic profiling (CGP) has been reimbursed under Japan’s universal health coverage since 2019, yet access remains uneven because designated institutions are concentrated in urban areas. Although CGP can identify actionable alterations, fewer than 10% of patients receive matched therapies, often due to geographic barriers to clinical trial enrollment. This nationwide survey evaluated institutional challenges in CGP implementation and explored the perceived role of telemedicine and decentralized clinical trials (DCTs) in improving equitable access.</p> Methods <p>A web-based questionnaire was distributed to professionals involved in CGP across government-designated hospitals for cancer genomic medicine between December 2024 and February 2025. Respondents provided institutional data and perceptions regarding CGP access, telemedicine use, and barriers to trial participation.</p> Results <p>A total of 194 professionals from 140 hospitals responded. On average, 23.5% of CGP-tested patients were referred from non-designated hospitals, often requiring multiple in-person visits. Fifty-eight percent of respondents supported telemedicine for both informed consent and result disclosure, citing reduced travel burden, while concerns included digital literacy and institutional workload. Sixty-one percent reported that over half of eligible patients declined genotype-matched trials due to travel distance. Institutions facing higher dropout rates expressed greater support for DCTs (67% “strongly needed”).</p> Conclusion <p>This nationwide study identified major geographic and logistical barriers to equitable precision oncology in Japan. Most institutions view telemedicine and DCTs as essential to expanding access to genomic testing and clinical trials. Japan’s experience may offer insights for other healthcare systems considering integration of telemedicine into national precision oncology frameworks under universal health coverage.</p>