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Cancer survivorship is now a pivotal phase in the cancer care continuum, with an increasing number of individuals living beyond cancer treatment. Survivorship programs focus on improving the health and well-being of individuals diagnosed with cancer from the time of diagnosis, through treatment and beyond. These programs aim to help survivors live longer and with a better quality of life, addressing not only physical health, but also the emotional, social and practical needs of individuals navigating life after cancer (WHO, n.d.). Healthcare professionals and patients raised awareness on the rising number of cancer survivors, combined with observed gaps in post-treatment support. This prompted the Directorate of Cancer Care Pathways (DCCP) (Marmarà et al., 2025), and ultimately the Ministry for Health and Active Ageing, to better prioritize cancer survivorship and resulted in the development of a national approach to cancer survivorship. Following the introduction of a Survivorship Unit within the DCCP in 2019, which aimed at supporting patients beyond active cancer treatment and improving their long-term quality of life, Malta established a Cancer Survivorship Team (CST) the same year, which operates under the DCCP’s Survivorship Unit.
The CST is hosted within the Sir Anthony Mamo Oncology Centre (SAMOC), and comprises a practice nurse in cancer survivorship and a higher allied health practitioner (occupational therapy) acting as cancer rehabilitation coordinator. Together, they developed three core services: the Tailoring Recovery after Cancer (TRaC) classes, the Holistic Needs Assessment (HNA) clinics, and the one-to-one Survivorship Support (see paragraphs below). Cancer survivorship support is further strengthened through integration with clinical support services such as occupational therapy, physiotherapy, psychological services, dietetics, speech and language pathology, social work and dental hygiene. In addition, aromatherapy and sexual counselling are delivered by volunteers, and the CST (or oncologists) can refer patients to collaborating non-governmental organizations (NGOs), based on individual needs.
The TRaC classes are multidisciplinary classes introduced in 2020 to provide structured education and support for individuals who have completed active cancer treatment. These sessions are led by the CST and involve multiple professionals who share expertise in: managing long-term side effects and emotional well-being; fear of recurrence, depression, anxiety, and isolation; coping strategies and goal setting; healthy lifestyle guidance including nutrition and exercise; sexuality, body image, fertility and relationships; vaccination and infection control; and stress and fatigue management. Classes also include peer-sharing, which strengthens the social connection between survivors and allows the CST to tailor sessions to participants’ real-time feedback.
The HNA clinic was launched in May 2021 and provides a structured yet flexible space for cancer survivors to express their physical, emotional, psychological and social concerns post-treatment. Referrals come from healthcare professionals across oncology, and the CST develops individual assessments, providing tailored care and signposting to relevant support services. This clinic explores emotional, functional, psychological and social dimensions of survivorship, ensuring that timely and appropriate support is offered to help patients reintegrate into everyday life. Expansion of the HNA clinic to other healthcare facilities is ongoing.
The one-to-one Survivorship Support service complements or substitutes TRaC classes for individuals who prefer private sessions. The content mirrors that of the group programme and is delivered through face-to-face or telehealth consultations. This flexibility enhances accessibility and personalisation of care. Additionally, the CST provides one-to-one telephone calls with cancer survivors to empower and guide them through their journey beyond cancer. These calls offer emotional support, practical advice and motivation to help survivors regain control over their lives.
In addition to the CST, the community clinics of Fgura and Attard localities have been running survivorship and surveillance clinics since 2022. Grounded in primary healthcare settings and supported by the DCCP, four general practitioners, specifically trained on cancer survivorship surveillance, establish protocols with multidisciplinary clinicians to perform a holistic clinical assessment of cancer survivors’ health needs and issue referrals when needed. The Community Clinics of Fgura and Attard localities then accept these referrals for prostate, thyroid, lung and breast cancer survivors, and offer individuals morning or afternoon appointments.
Enablers: The model’s strength lies in its adaptability with services being delivered individually or in groups, in-person or remotely, therefore enabling a high scalability across the country (service delivery); the CST’s structure ensures continuous coordination, while existing hospital-based allied health services enhance delivery without requiring large-scale investment, therefore securing the programme’s sustainability (financing, governance); and the close collaboration between nursing and allied health professionals ensures a holistic approach that spans medical, functional, and psychosocial domains (governance, healthcare workforce). Finally, Malta’s survivorship model was developed based on international models and guidelines. The UK’s Holistic Needs Assessment framework and the US Institute of Medicine’s Lost in Transition report were used to identify core domains of survivorship and develop personalized care plans. International standards from the WHO, the European Society for Medical Oncology (ESMO), and the National Cancer Survivorship Initiative (NCSI) were used to develop assessment frameworks that include psychosocial support components and patient education approaches. Alignment with international practice was key in both strengthening the design and credibility of Malta’s model.
Barriers: Workforce recruitment and upskilling were significant challenges to the initiation of survivorship services in Malta, especially as no dedicated training pathways existed before their implementation. Patient engagement and retention were also an initial blocker as stigma surrounding cancer and mental health persists in Malta and across Europe. This was tackled through proactive outreach, telephone follow-ups an increased visibility of the programme, as well as active efforts from the CST to enhance trust and normalise conversations about quality of life. Nonetheless, the absence of an integrated system to identify and monitor cancer survivors once they have completed active treatment still challenges systematic follow-ups, requiring manual coordination between oncology professionals, primary care professionals, and the CST. Finally, before the creation of the Survivorship Unit and CST, survivorship support existed only informally and on a small scale, so that this national programme had to be built from the ground up, including workflows, referral pathways, assessment tools and educational content, further highlighting the necessity to align with international models and guidelines.
Since its establishment in 2021, these support services have reached 2 570 people through the HNA Clinic, 500 people through TRaC Classes, and 7 250 people through one-to-one interventions. The establishment of the Survivorship Unit and CST in 2019 marked a turning point in embedding long-term post-treatment support within the national cancer care pathway and contributing to people’s quality of life. Malta is the first EU Member State to have established such a survivorship programme. Hence, Malta’s Cancer Survivorship Team exemplifies how small health systems can implement robust, scalable and compassionate survivorship services. By rooting care in patients’ lived experiences and fostering interdisciplinary collaboration, the CST provides a blueprint for other countries to improve long-term outcomes for cancer survivors. This case study invites other EU nations to consider adopting or adapting similar models to address the growing demand for structured survivorship care.
For more information
WHO (2022). Malta “nurse navigators” embody patient-centred care. Available at: https://www.who.int/europe/news-room/15-09-2022-malta--nurse-navigators--embody-patient-centred-care (Accessed 18/11/2025).
Zammit, M. (2022). WHO hails “new” system of cancer care in Malta. Times of Malta. Available at: https://timesofmalta.com/article/hails-new-system-cancer-care-malta.991436 (Accessed 18/11/2025).
