A life-saving cancer drug hailed as a breakthrough in modern medicine has become a symbol of a deeply unequal global health care system. A yearlong investigation by the International Consortium of Investigative Journalists (ICIJ) has revealed how Merck & Co. has maintained sky-high prices for its blockbuster drug Keytruda, effectively locking out patients worldwide while generating staggering profits.
Titled 'The Cancer Calculus', the investigation, conducted with 47 media partners across 37 countries, “pulls the curtain back on precisely how Merck maintains its dominance,” drawing on hundreds of interviews, pricing data, patent records and corporate documents.
Keytruda: The life-saving cancer drug
A game changer in cancer treatment, Keytruda, known generically as pembrolizumab, works by harnessing the body’s immune system to attack cancer cells. Since its approval by the U.S. Food and Drug Administration in 2014 for advanced melanoma, it has been cleared for 19 different types of tumors. But while its clinical impact is widely acknowledged, its accessibility remains sharply contested.
A ‘patent fortress’ extending monopoly
At the heart of the investigation is what experts describe as a “patent fortress.” ICIJ found that there are at least 1,212 patent applications linked to Keytruda across 53 countries and regions. While the drug’s primary patents are set to expire in 2028, Merck has continued filing secondary patents that could extend its exclusivity in the United States until at least 2042.
“These additional patents, which can overwhelm and deter competitors, could deny hundreds of thousands of patients cheaper alternatives over the next 15 years,” the investigation notes.
Merck, however, rejected the criticism, telling ICIJ that it is “a common myth that pharmaceutical companies ‘game the patent system’,” and argued that patent counts do not determine when generics enter the market.
Sky-high prices, uneven globally
The investigation highlights stark disparities in pricing. ICIJ found that a 100 mg vial of Keytruda costs about $850 in Indonesia but as much as $6,015 in the United States. Treatment, typically administered over months or years, can reach $416,000 in the U.S. based on list prices.
Even within countries, costs vary widely. In the U.S., a single 200 mg treatment can range from $5,858 to $43,800 depending on insurance coverage and provider billing practices.
Merck defended its pricing strategy, stating it has a long history of “responsibly pricing our medicines to reflect their value to patients, payers and society,” and that prices are set “differentially across markets” based on multiple factors, including governments’ ability to finance health care.
Yet critics argue that such pricing has less to do with innovation costs and more with maximising returns. A separate analysis cited in the investigation estimated Keytruda’s research and development costs at between $1.9 billion and $4.8 billion — just 1 to 3 per cent of its roughly $163 billion in global revenue since launch.
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‘Calculated dosing’ and expanding use
The investigation also raises questions about how the drug is prescribed. Researchers found that Keytruda is often given at higher doses or for longer durations than necessary.
According to the World Health Organization, switching lung cancer patients to weight-based dosing could save up to $5 billion globally by 2040. Several countries, including the Netherlands, Canada and Israel, have already begun adopting such approaches.
Hospitals in Singapore, Malaysia and Taiwan have reached similar conclusions, suggesting that current dosing practices may not always be cost-efficient.
Merck responded by emphasising that its approved dosing regimens are based on “wide-ranging preclinical data and extensive clinical evidence,” adding that treatment decisions depend on cancer type and whether the drug is used alone or in combination.
Influence on prescriptions
Another key finding relates to financial relationships with doctors and patient groups. The investigation found that Merck invested heavily in consulting payments, research grants and other ties that can influence prescribing patterns.
“In the U.S. alone, records show, Merck made nearly $52 million in Keytruda-related consulting and other payments to health care professionals from 2018 to 2024,” the report states, noting that five doctors received more than $1 million each.
Studies cited in the investigation suggest that such payments can increase prescriptions — sometimes without improving patient survival rates.
Blockbuster profits, global inequities
Keytruda has generated around $163 billion in sales since 2014, making it one of the world’s best-selling drugs. In 2025 alone, it brought in $31.7 billion, accounting for nearly half of Merck’s total revenue, with 60 per cent of sales coming from the United States.
The investigation also points to shareholder returns, noting that the company has distributed nearly $75 billion in dividends and spent $43 billion on share buybacks.
Meanwhile, patients across the world struggle to afford treatment.
ICIJ found at least 632 cases in 51 countries where patients turned to crowdfunding platforms to pay for Keytruda. Others resorted to legal action against governments or insurers, sometimes dying before their cases were resolved.
Doctors in lower-income countries are often forced into ethical dilemmas, rationing treatment and deciding which patients receive the drug.
The India story: high cost, limited access
In India, Keytruda is available as a 100 mg/4 ml injection costing between Rs 1.5 lakh and Rs 2.16 lakh per vial. A full course of treatment, typically lasting up to 18 months, can cost as much as Rs 50 lakh, while annual costs may reach Rs 1.2 crore.
As a result, the drug remains out of reach for most patients. It is also not included in India’s National List of Essential Medicines, limiting coverage under public health schemes such as Ayushman Bharat-Pradhan Mantri Jan Aarogya Yojana.
The high price has also fueled a dangerous black market. In 2024, Delhi Police busted a major counterfeit drug racket involving fake versions of high-end cancer medicines, including Keytruda — underscoring how scarcity and unaffordability can drive illegal supply chains.
Globally, the investigation documented similar cases, including fake Keytruda being supplied to hospitals in Mexico.
A broken system?
Despite its transformative impact, extending survival for patients with melanoma, lung cancer and other difficult-to-treat tumors, Keytruda has become, in the words of the investigation, “a case study of a broken global system for drug pricing and distribution.”
The report argues that regulatory mechanisms such as accelerated approvals and orphan drug designations have also played a role in expanding the drug’s market while reinforcing its commercial dominance.
Ultimately, The Cancer Calculus raises a fundamental question: how should the world balance innovation, profit and access?
“The project shows that a system that protects pharmaceutical pricing monopolies prioritizes profit over access,” the investigation concludes, warning that the consequences are measured not just in dollars, but in lives.
For hundreds of thousands of patients worldwide, that balance is not theoretical — it is the difference between treatment and no treatment at all.
This story is done in collaboration with First Check, which is the health journalism vertical of DataLEADS
