Before the introduction of the fast-track system, referrals for suspected cancer were inconsistent and often paper-based, leading to long wait times and fragmented communication between primary and secondary care. National audits revealed that late-stage cancer diagnosis was far too common, with missed opportunities for early intervention (Attard, et al., 2020; Magri, et al., 2015). To address this, Malta’s new Directorate for Cancer Care Pathways (DCCP) (Marmarà et al., 2025b; Ministry of Health and Active Ageing, n.d.a.) initiated a national drive to reduce the time from “suspicion to specialist”, with a digital solution at its core.
In 2019, a multidisciplinary team, composed of the DCCP director, policy-makers, colorectal surgeons, fast-track coordinator, public health consultants, and IT experts, was established with the aim to fast-track suspected colorectal cancer cases. With the creation of this multidisciplinary team, Malta reached a critical milestone whereby a pilot project was launched involving 40 general practitioners (GPs) who could refer patients with suspected cancer through a new integrated electronic referral system hosted on the national Digital Health Platform (iPAAC, n.d.). The initiative aimed to accelerate diagnosis, reduce cancer-related mortality and improve life expectancy. These e-referrals allow GPs to attach essential pre-operative test results (e.g., ECGs, blood work, imaging), streamlining triage and reducing unnecessary hospital visits. To facilitate uptake across the years, an app was installed on all Health Centre computers, and targeted information sessions were held with private GPs to promote the system. Once submitted, an automatic SMS confirms receipt of the referral, and the GP can log into the system to track its progress – a system continuously monitored by the fast-track team.
The project has since been expanded nationwide, and currently 450 Health Centre GPs and Family Practitioners are using the system to refer patients with suspected cancer (iPAAC, n.d., Ministry of Health and Active Ageing, n.d.b.). As of end of 2025, the program now encompasses fast-track for suspected lung, breast, haematological, prostate, upper gastrointestinal, head and neck, and skin cancers, and is currently piloting gynaecological cancers. Each e-referral form was carefully designed by the DCCP Director, fast-track coordinators, the respective surgeons of a particular cancer site and primary care providers, in collaboration with IT specialists and patient feedback to ensure clinical relevance and ease of use.
Since the start of the fast-track service, 5771 referrals were received and issued using the fast-track system, showing a significant year-on-year increase in referrals. This growth reflects both increased GP engagement and the system’s integration into routine care. Patients benefit from shorter waiting times, often following a two-week timeframe for initial specialist appointments and a clearer, more coordinated care pathway. Critical to the success of the system is the collaboration of the fast-track cancer team, who work alongside triaging consultants to prioritize cases, contact patients, and coordinate follow-up with cancer nurse navigators (Marmarà et al., 2025a). They also offer telephone support to both patients and GPs. Their person-centred approach ensures that while the system is digital, the care remains deeply humane.
Enablers: Embedding the system in every health centre computer and designing intuitive forms to ensure the accessibility of the tool was key to drive engagement (information). The phased rollout of the initiative enabled continuous refinement, with the development of each cancer pathway providing learnings for the next (governance); triage being primarily clinical, not just digital, with real-time reviews by specialists was crucial to success (service delivery). Multidisciplinary collaboration was key to the design of an adequate system, with a tailored multidisciplinary team adapted to each cancer type (healthcare workforce, governance). A final factor was designing digital solutions that empower the healthcare workforce rather than replacing health professionals. The technology supports faster care, but outcomes are improved through human connection (information, service delivery, healthcare workforce).
Barriers: Health professionals lacked knowledge and confidence on how to use the e-referral system (iPAAC, n.d.) meaning that adequate training of health professionals is critical to success (health workforce). Each cancer type follows a specific care pathway, and therefore there cannot be a one-size-fits-all system, further reinforcing the importance of adopting an incremental approach to implementation (governance, service delivery). Designing and testing e-referral systems require substantial funding, but also the creation of new coordinator roles, which implies dedicated resources (financing, resources). Variations between public or private settings, and the targeted cancer type can give rise to disparities in the implementation, and pilot initiatives are key to identifying and mitigating these issues early in the implementation process (governance).
Malta’s Fast-Track E-Referral System was recognized by the World Health Organization (WHO) during its 2019 cancer care mission to Malta. The WHO cited it as an example of digital innovation that enhances equity, quality and timeliness of care (Lamtargi and Zammit, 2025; WHO, 2022). This programme also aligns with EU Cancer Mission goals, particularly the target of having 90% of eligible patients enrolled in National Cancer Pathways by 2030 (European Commission, 2021). Hence, Malta’s digital-first, patient-focused strategy provides a replicable framework for other member states.
Malta is currently developing digital referrals for other cancers, with plans to integrate AI-assisted triage and to link the system to Patient-Reported Experience Measures (PREMs) and Outcomes (PROMs). These next steps will help evaluate how fast-track access translates into real-world patient benefit, both clinically and emotionally.
Lessons learned: The development of Malta’s Fast-Track E-Referral System demonstrates how focused innovation can rapidly transform cancer care delivery. In a world where early diagnosis saves lives, Malta’s model offers a practical, patient-centred and scalable pathway for other countries to follow.
