For years, director of Cancer Care Pathways Dr Danika Marmara has worked to reshape cancer care in Malta around one central idea: that patients should not be left to navigate diagnosis, treatment and survivorship on their own.

A patient who once told her, "this is my last day on the planet and you will not see me again", helped shape the philosophy that would go on to define Marmara's work in cancer care, whose role has focused not simply on improving services, but on trying to redesign the experience of cancer care around the needs of patients and their families.

Cancer care in Malta has undergone a significant transformation over the past decade, moving steadily away from a model in which patients could be left waiting, uncertain and poorly guided, and towards one that is far more structured around the full pathway of care, from the first suspicion of cancer, right through to treatment, survivorship and beyond.

Marmara's work has centred on one core principle: that cancer care should not simply be about treating disease, but about guiding a person through one of the most difficult and disorienting experiences of their life.

She played a central role in developing Cancer Care Pathways in Malta, and said the philosophy behind this approach was born not only out of academic study and professional experience, but from repeatedly seeing what happened to patients the moment they were given a diagnosis.

Marmara said that one of the most defining moments in a patient's journey is the point at which they are told they have cancer - a moment that often changes everything.

"When they are told their diagnosis, they go from being an okay person, to someone who has cancer, and that is it," she said.

Patients would receive a diagnosis, be referred to hospital and left to navigate the system largely on their own.

"I was always interested in wanting to know more about the patient journey, the patient pathway, and wanting to be able to support that patient as soon as there is a diagnosis," she said.

A vision shaped early

Marmara said her drive to work in healthcare and focus on alleviating suffering was influenced early in life, particularly by her mother, a nurse and midwife who trained generations of professionals.

"I have something in my blood for empathy and that came from my mum. As I grew in healthcare, I had this focus to want to alleviate human suffering," she said.

Her academic path reflected that focus, progressing from medical imaging to specialised study in mammography, research in London and eventually a doctorate.

At 29, while completing her PhD on cancer, she said she already had a clear vision of wanting to improve how cancer care was delivered.

When she entered Sir Paul Boffa Hospital back then, Marmara said she was met with scepticism.

"People thought I was crazy," she said.

She recalled being told that she was too young, that healthcare was male-dominated, and that cancer was simply "what it is" - widely seen as a death sentence.

"They said there was no space for me and that I would have to find my own space," she said.

She did just that, asking for a desk and setting herself up in a corner with a broken chair.

Listening before changing

Marmara spent her first four months speaking directly with patients and analysing thousands of files to understand where the system was failing.

"They gave me so much in those four months. They were the crucial point, where I understood that patients were falling out of the system," she said.

What she found was a system marked by delays, poor coordination and a lack of clear support structures.

"There were physical files running around, getting lost. The patient needed support and did not know who to contact," she said.

At the time, waiting times were particularly long, with colorectal cancer patients facing delays of up to seven months for a colonoscopy.

She also recognised that cancer could not be approached as a single condition.

"I couldn't look at cancer as a disease as a whole, I needed to look at them by speciality rather than just as a number," she said.

Each group of patients had different needs, but a common theme emerged: patients wanted guidance and a clear point of contact, Marmara said.

Building Cancer Care Pathways

Marmara's response was to develop a structured approach to cancer care, creating the Directorate for Cancer Care Pathways.

"I started building it literally from scratch, from nothing; it did not exist," she said.

While Malta had a national cancer plan, she said that strategies alone are not enough.

"Sometimes strategies are created, yet they end up sitting pretty on our shelves. A person or team is needed to implement the strategy in practice," she said.

The model she developed focused on three main pillars: fast-track referrals, patient navigation and survivorship programmes.

One of the most immediate issues identified was the length of time patients spent moving through the system.

Marmara described how referrals, appointments, imaging and treatment were often delayed by inefficiencies, including lost paperwork and long waiting lists.

The FastTrack system was introduced to address this, allowing GPs to refer suspected cancer cases through an electronic platform to a dedicated team that coordinates appointments and investigations.

"We created a network with GPs, and moved the patient to the first urgent appointment with a specialist," she said.

What began as a pilot with 45 GPs has grown to include around 450 doctors, Marmara said.

The impact has been significant, with waiting times in some pathways reduced from seven months to between one and one-and-a-half months.

"There is this structured, tight network, a robust link between the hospital team and the GP and the patient," she said.

Patients are contacted directly, guided through preparations for tests and kept informed throughout the process, Marmara said.

The role of the nurse navigator

Alongside reducing delays, Marmara sought to address the lack of support patients experienced after diagnosis.

Drawing on models abroad, she developed the concept of the nurse navigator, a specialised professional who acts as a constant point of reference for patients.

Each navigator focuses on a specific cancer type, reflecting the differing needs of patients.

The role extends beyond coordination, providing emotional support and helping patients understand their condition and treatment, she said.

"Often, when patients are told that they have cancer, they stop listening, their brain becomes foggy," Marmara said.

Navigators help break down complex information and remain accessible to patients throughout their journey.

Marmara said that the model has also reduced pressure on emergency services.

"The nurse navigator role has reduced 30% of admissions to the emergency department," she said.

Previously, patients often turned to emergency services due to uncertainty or lack of support. Now, with a direct point of contact, many issues can be managed within the system, she said.

However, Marmara acknowledged that resource constraints remain.

"I would like thousands of navigators, but the resources are what they are," she said.

A multidisciplinary approach

Marmara stressed that cancer care relies on a multidisciplinary approach, bringing together specialists to decide on treatment plans.

"You need the pathologist, oncologist, surgeon, nurse navigator, you need the whole team," she said.

Importantly, she said, the nurse navigator represents the patient's voice within these discussions.

Another gap identified in patient feedback was the lack of support after treatment ends.

"When they completed treatment, they felt lost," Marmara said.

In response, survivorship programmes were introduced to support patients as they transition back to daily life.

The aim is to ensure continuity of care and avoid leaving patients without support once treatment is complete.

Expanding care into the community

More recently, cancer care has extended beyond hospital settings, with services increasingly delivered in patients' homes, Marmara said.

A pilot outreach programme launched in 2025, and formally introduced this year, allows certain interventions to be carried out at home, particularly for frail patients.

"There are so many interventions that you can do in patients' homes," Marmara said.

This approach reduces logistical burdens on families and eases pressure on hospital services, she said.

"Sometimes it is not even possible to travel because the patient is weak and it affects the whole family," she said.

Marmara emphasised that cancer care must also account for the needs of families and caregivers.

She said that support structures include psychological services, communication with relatives and collaboration with NGOs.

Malta's approach has attracted international attention, particularly from the World Health Organisation and the European Commission.

"They were particularly interested about the concept of navigation," Marmara said.

She argued that Malta's size can be an advantage, allowing for quicker coordination and implementation.

"If it works in Malta, it can probably work in other countries," she said, adding that over the past decade, cancer survival rates have improved significantly.

"We've seen survival rates increase drastically, now we have close to around 50% of cancer patients surviving," she said.

Breast cancer outcomes, she added, are particularly strong, with survival rates exceeding 85-90% in Malta, while other countries are still struggling.

Marmara said that these improvements are also linked to increased specialisation within the system, with more oncologists and specialised teams.

Despite progress, Marmara acknowledged that significant challenges remain, particularly in staffing and capacity.

"The most challenging thing is always finding human resources," she said.

She also pointed to pressures in emergency care, where oncology patients may face long waits due to competing priorities.

"Some patients are stuck for five, six hours in emergency," she said.

She said that research shows that around 50% of patients may require emergency care after chemotherapy due to complications.

Marmara said that efforts are underway to create alternative pathways and reduce reliance on emergency departments.

'Never too young to dream big'

Reflecting on her journey, Marmara said that her work remains centred on the needs of patients.

"Patients do not just want the nice building, they want us to focus on the person," she said.

Asked about receiving the People's Choice Award at the recently held Mara 2026 awards, Marmara said she had not expected it, and that she had been nominated both by patients and colleagues.

"When it comes to these things, I sometimes feel awkward, but for me, having a People's Choice Award means that the people are actually saying a big thank you, but that they want more and even better," she said.

"Patients want more services, they want that the patient is at the centre and the family needs to be our top priority. It brings a lot of responsibility on my shoulders, to make cancer services even better," she said.

At the same time, she said, she sees the heartache not only of patients and families, but also of professionals who are giving so much of themselves within the system.

She added that she tries as much as possible to ensure teams are supported and referred to the appropriate support systems, while also balancing her own life as a director, mother and wife.

"My mind is always on constant, but I do take the time to step back and refresh myself because we all need it," she said.

Looking back to the vision she had at 29, she said her message to younger people entering the field would be not to underestimate either their ideas or their capacity to act on them.

"At 29, I just had a vision, a plan in my mind I used to dream about," she said.

"My words to all young people is never to give up and never to think that their dream is small. They need to dream big."