A Blockbuster Drug, a Global Divide

The International Consortium of Investigative Journalists (ICIJ), together with 47 media partners across 37 countries, published the findings of its year-long 'Cancer Calculus' investigation on April 13, 2026. The central finding: U.S. pharmaceutical giant Merck & Co. has deliberately maintained extraordinarily high prices for its blockbuster cancer drug Keytruda (pembrolizumab) while systematically deterring competition.

Keytruda is a PD-1 inhibitor that weaponizes a patient's immune system against cancer cells. First approved by the U.S. Food and Drug Administration (FDA) in 2014 for advanced melanoma, the drug has since gained approval for 19 types of tumors. In 2025 alone, it generated $31.7 billion in revenue — nearly half of Merck's total sales.

Why It Matters: Price Gap Equals Life Gap

The most striking figure in the ICIJ investigation is the disparity in prices across countries. The list price for a single 100mg vial of Keytruda ranges from approximately $850 in Indonesia to $6,015 in the United States — a nearly sevenfold difference.

Typically administered as an intravenous infusion at 200mg every three weeks or 400mg every six weeks for up to two years, the total treatment cost at U.S. list prices reaches approximately $416,000. Insurance companies often stop covering the drug after the initial two-year period, further burdening patients whose treatment must continue.

When President Donald Trump summoned top pharmaceutical executives to the White House in December to push for lower drug prices, Merck CEO Robert M. Davis attended — but made no commitment to cut Keytruda's price, protecting the drug's $31.7 billion annual revenue stream.

This is not merely a corporate profit issue. It reveals a structural inequality in which cancer patients' access to the same drug depends on which country they were born in. According to multiple international media reports, in some lower-income countries, the drug isn't even covered by national health systems, effectively denying patients any chance of treatment.

How We Got Here: Building a Patent Fortress

Keytruda's pricing issues were foreshadowed at the time of its 2014 FDA approval. Merck justified the premium price by citing the drug's superior efficacy over conventional chemotherapy. Since then, the company has pursued two core strategies.

The first is what the ICIJ terms a 'patent fortress.' According to the investigation's analysis, Merck has continuously expanded Keytruda's patent portfolio — covering manufacturing processes, dosing methods, and new indications — to prevent biosimilar competitors from entering the market. This is not unique to Merck; it is a widely used tactic among major pharmaceutical companies to sustain monopoly pricing on high-cost biologics.

The second strategy is indication expansion. Over 12 years, Merck broadened Keytruda's approved uses from melanoma to 19 cancer types including lung, head and neck, bladder, and breast cancers. The investigation notes that for some indications, clinical benefit is more limited, and studies suggest lower doses may be equally effective — yet Merck has not pursued lower-dose approvals, as doing so would reduce revenue.

The investigation is based on more than 1,000 public records requests in 27 countries, hundreds of interviews with oncologists, patients, patent experts, regulators, and pharmaceutical insiders, as well as exclusive pricing data, patent analyses, and thousands of pages of corporate documents.

Outlook [Expert Analysis]

This investigation is likely to intensify policy pressure on global drug pricing structures. In the United States, Medicare's expanded drug price negotiation authority is already accelerating reform, while Europe is advancing joint health technology assessment (HTA) frameworks.

The timeline for biosimilar market entry is a critical variable. With Keytruda's core patents expected to expire around 2028, multiple companies are developing pembrolizumab biosimilars. However, depending on the strength of the patent fortress, meaningful market competition could be delayed by several additional years.

The fundamental question this investigation poses is straightforward: who decides the price of a life-saving drug, and by what standard? The answer that 37 countries' journalists are collectively demanding may take years to arrive — but the pressure is now undeniable.