Case Studies

The impetus for Malta’s cancer nurse navigation programme was born from the establishment of the Directorate for Cancer Care Pathways (DCCP) in 2014 (Marmarà et al., 2025). Tasked with identifying service gaps, improving care timelines and overall cancer care, Dr. Danika Marmarà conducted extensive quantitative and qualitative research and data analyses through national audits and patient interviews, which revealed system delays, fragmented care coordination and barriers to timely access, especially for those who are navigating complex diagnostic and treatment pathways or are socioeconomically disadvantaged. Laying a strong argument for change, these findings constituted the foundation for the establishment of the DCCP, supported by the Ministry for Health. Building on these preliminary findings, the newly established DCCP (under the direction of Dr. Danika Marmarà) developed a phased, evidence-based action plan and successfully secured the human and financial resources necessary to launch Malta’s first Cancer Nurse Navigator (CNN) service in 2017.

The aim of the cancer nurse navigation system is to empower patients to make informed decisions while feeling supported – physically, emotionally and spiritually. Yet, nurse navigation was a novel concept in Malta, and job descriptions were developed from the ground up for each cancer site. A comprehensive competency booklet and training standard operating procedure were also designed, drawing on international best practices (DCCP, internal document, 2017). Each new nurse navigator undergoes an intensive three- to four-month training programme, including shadowing, international exposure and a supervised independent practice phase. This is paired with a baseline gap analysis in their cancer speciality, after which they co-develop a structured care pathway with clinical teams. The CNN’s role is holistic and multifaceted:

• Engaging patients from the moment of diagnosis
• Educating patients about treatment and possible side effects
• Providing complete holistic care across the whole care pathway
• Playing a central role in multidisciplinary team meetings by supporting care coordination and advocating for the patient’s wishes
• Reducing barriers to timely care, by fast-tracking tests, referrals and treatments, providing advice, and facilitating care plans and after care reviews
• Providing phone-based support and following up on patients’ needs
• Advocating for patients at every step

Malta’s approach was deliberately incremental. After the initial success of the colorectal service, new CNN roles were introduced one by one, focusing on quality, sustainability and training. In 2025, Malta boasts 12 Cancer Nurse Navigators covering a wide range of cancers, including lung, breast, gynaecological, prostate, haematological, urological, head and neck, and rare cancers such as sarcoma and melanoma. Over 10,636 patients have received navigation support, with over 62 540 telephone interventions and 76 078 face-to-face reviews since the programme began. Malta is now introducing national patient-reported experience measures to better understand the impact of navigation from the patient’s perspective. This ongoing evaluation will guide the next phase of development, including deeper integration with survivorship care, digital tools and community-based services.

Enablers: strong strategic planning and ministerial support (governance), evidence-based design (information), co-designed pathways grounded in patient feedback (service delivery, information, patient-centredness), dedicated infrastructure and time for training (healthcare workforce, resources), competency-based staffing and clear definition of roles (healthcare workforce), and annual review informing adaptative expansion (information).

Barriers: challenges remain in managing inter-professional boundaries (healthcare workforce, service delivery), securing dedicated office space (resources), and recruiting nurses with experience in the oncological field (healthcare workforce).

In 2019, a WHO mission to Malta specifically endorsed the nurse navigation model and highlighted that Malta’s CNN system demonstrated clear benefits, such as better treatment timeliness, higher patient and caregiver empowerment, better care adherence, and improved reported quality of life (WHO, 2022a; WHO, 2022b). The WHO recognition of the successful implementation of CNN, further catalyzed national investment and underscored the replicability of the model for other health systems, especially those seeking to implement EU Cancer Mission goals around timely and equitable care.

Malta’s nurse navigation programme exemplifies how vision, leadership and patient engagement can drive meaningful change, even in small or resource-limited health systems. The model offers a practical and inspiring roadmap for other countries looking to better humanise cancer care and ensure that no patient is left to navigate health systems’ complexity alone.

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