$163 Billion in Revenue, Millions Left Behind

The International Consortium of Investigative Journalists (ICIJ), working with 47 media partners over a year, has released the Cancer Calculus investigation — a sweeping probe revealing how pharmaceutical giant Merck & Co. has kept its blockbuster cancer drug Keytruda priced extraordinarily high while systematically suppressing generic competition. The investigation drew on 1,018 public records requests across 27 countries to obtain pricing, patent, and lobbying data.

Why It Matters

Keytruda (pembrolizumab) is an immunotherapy that restores the body's ability to fight cancer cells by blocking a pathway that some tumors use to evade the immune system — a fundamentally different mechanism than traditional chemotherapy. First approved by the U.S. Food and Drug Administration (FDA) in 2014 for advanced melanoma, it has since been approved for 19 types of tumors, reaching more than 3 million patients.

The problem is that price barriers are preventing this breakthrough drug from reaching countless patients. Annual treatment costs range from approximately $208,000 in the United States to $80,000 in Germany, $116,000 in Croatia, and $65,000 in South Africa. ICIJ analysis shows Keytruda is disproportionately expensive for median income earners in the U.S. and Eastern European countries like Bulgaria and Hungary compared to wealthier Western European nations. Government healthcare budgets are under strain even in wealthy countries. Since 2014, Merck has generated approximately $163 billion in Keytruda sales.

How Did We Get Here?

Keytruda's story begins in 2014, when the FDA first approved it for melanoma, the most aggressive form of skin cancer. Merck rapidly expanded its approved uses, and today holds 19 cancer indications — though some leading cancer researchers have questioned whether certain approvals offer limited clinical benefit.

Simultaneously, Merck executed an aggressive patent defense strategy. According to industry reporting, Merck and affiliated pharmaceutical companies filed at least 1,212 patent applications across 53 countries, regions, and territories, constructing what the investigation calls a 'patent fortress' around Keytruda. While its core patents are set to expire in 2028, this stream of follow-on patents could block biosimilar competitors for an additional 14 years, potentially until 2042.

Dosing strategy has also come under scrutiny. The World Health Organization (WHO) estimates that switching lung cancer patients to weight-based dosing could save $5 billion globally by 2040. Some leading cancer researchers contend that Merck has promoted higher doses than clinically necessary.

Merck's financial structure warrants attention as well. The company recorded profits in lower-tax jurisdictions to reduce its U.S. tax burden. Its 2025 annual report shows it paid approximately $1.6 billion in U.S. income taxes, compared with $4.5 billion abroad, including $2.1 billion in Switzerland. During the same period, Merck funneled nearly $75 billion in dividends to shareholders and $43 billion into share buybacks. The company also distributed tens of millions of dollars in consulting fees and other Keytruda-related payments to U.S. doctors and healthcare professionals.

What Comes Next [Expert Analysis]

Experts suggest the Cancer Calculus investigation is likely to ignite fresh debate on global drug pricing policy and patent reform. As long as Merck's patent fortress holds, affordable biosimilar alternatives are likely to remain locked out until the 2040s, sustaining pressure on national healthcare budgets worldwide.

Regulators and international bodies may respond. Given that the investigation is grounded in public data from 27 countries, policymakers across multiple nations are likely to pursue stronger pricing transparency requirements and patent system reforms. If WHO's weight-based dosing recommendations are codified into policy, significant cost savings could become a reality.

Merck has defended its pricing practices — senior vice president Johanna Herrmann maintained the company's position — but CEO and chairman Robert M. Davis declined to comment publicly. The central question raised by Cancer Calculus remains stark: whose interests does pharmaceutical innovation ultimately serve?