How Merck turned its wonder drug into a blockbuster — and priced out cancer patients worldwide
Just days before Christmas 2025, leaders of nine pharmaceutical companies clustered in the Roosevelt Room of the White House, where Teddy Roosevelt’s 1906 Nobel Peace Prize once hung. Photographers flocked for pictures as the executives, three women and six men, stood awkwardly, tapping their feet and drumming their fingers while waiting for President Donald Trump. The pharma chiefs had all struck deals to slash prices on some of their flagship drugs.
Nearly 15 minutes passed before Trump entered the room, trailed by Health and Human Services Secretary Robert F. Kennedy Jr. and several senior officials. The president glanced at the executives.
“Wow, what a group of people,” Trump said. “They make a lot of money.”
Collectively, their annual compensation topped $100 million. But only one — the bespectacled corporate lawyer with a goatee — was at the helm of a $65 billion drug juggernaut with a lifesaving medicine that was unaffordable for much of the world: Robert M. Davis, CEO and chairman of Merck & Co., maker of the anti-cancer blockbuster pembrolizumab. Brand name: Keytruda.
Trump promised drug prices would plummet “fast and furious” because of the new deals. Before the ceremony ended each executive stepped to the lectern to say a few words. When it was Davis’ turn, he declared “100%” support for the president’s actions.
Merck CEO Robert M. Davis, wearing a blue suit, stands between the heads of other major pharmaceutical companies as President Donald Trump announces a deal to lower drug prices at the White House in December 2025.
“I reflect on your goal of driving affordability and access to Americans but equally of getting prices up outside the U.S.,” Davis said.
He vowed Merck would drop prices on a diabetes drug and a cardiovascular pill, but he didn’t say anything about cutting the cost of Keytruda, which accounted for $31.7 billion in sales in 2025 and for nearly half of Merck’s revenue. In fact, the New Jersey-based drug giant would be making life tougher for so many cancer patients worldwide.
An investigation by the International Consortium of Investigative Journalists reveals how one of the world’s largest drugmakers deployed tactics to both inflate the volume of prescriptions and keep the price high through lobbying and by seeking to delay cheaper versions of the drug from reaching hundreds of thousands of cancer patients in the coming years. This is playing out as governments around the world spend growing amounts on Keytruda, with steep prices straining government budgets, even in wealthy countries. List prices range from about $80,000 for a year’s treatment in Germany to $208,000 in the U.S., $93,000 in Lebanon to about $130,000 in Colombia, $65,000 in South Africa to $116,000 in Croatia.
Cancer is a growing public health threat, responsible for nearly 1 in 6 deaths worldwide. Projections show cancer rates rising particularly in lower-income countries where Keytruda remains largely unaffordable. The death toll is forecast to surge by 75% to 18.6 million in 2050, with the cost of some new therapies already exceeding $1 million per patient.
Living with or beyond a cancer diagnosis brings about profound costs — physical, emotional and financial. Some patients are so desperate for Keytruda that they turn to the black market to get the drug for less money, though they don’t know if it’s the drug or a counterfeit version. Other patients seeking Keytruda face harrowing bureaucratic obstacles and end up suing their governments for access to the drug; not all of them survive long enough to learn the court’s ruling.
Reporting by ICIJ’s media partners across five continents paints a picture of deep and dangerous inequity:
In India, families seeking Keytruda rely on a frayed safety net — poor insurance coverage, Merck’s patient assistance program and out-of-pocket funds. In Brazil, the world’s seventh most populous country, most cancer patients can’t afford Keytruda, and thousands turn to the courts to get it. In South Africa, where the vast majority of citizens are not able to afford private health care and the typical monthly income for a household is under $500, a single dose of Keytruda costs roughly 10 times as much: $4,904.
Cancer patients receiving treatment in the oncology unit at the public hospital in Quetzaltenango, Guatemala.
In the United Kingdom, research shows that Keytruda tops the list of drugs for which the cash-strapped National Health Service overpays. For some lung cancer patients, the NHS has been paying five times as much for Keytruda than it should, according to cost-effectiveness data from the University of York shared with the Bureau of Investigative Journalism, ICIJ’s U.K. partner. And in Guatemala, one doctor dealing with limited access had to choose two among his many patients to receive the drug.
“What’s left for me to do? To play God,” said Julio Ramirez, head of the oncology unit at the regional public hospital in Quetzaltenango, Guatemala’s second largest city. “The first patient who arrives, that’s who I’m going to give the treatment to because that’s all I can do.”
The Cancer Calculus, a yearlong investigation by ICIJ and 47 media partners in 37 countries, is based on hundreds of interviews with oncologists, cancer patients and their families, patent experts, regulators, pharmaceutical industry insiders and others, as well as exclusive pricing data and patent analyses and thousands of pages of company presentations, patent board documents, lawsuits and corporate and regulatory records. ICIJ’s media partners also unearthed public health records, meeting minutes, pricing and reimbursement data, and other documents through 1,018 public records requests in 27 countries.
The investigation explores how Merck, known as MSD outside the U.S. and Canada, employed aggressive but legal tactics to increase its Keytruda revenues and make the drug one of the bestselling ever — at the expense of some patients.
Among the project’s findings, we report:
- Merck and other cancer research businesses exploited the patent system to build a fortress around Keytruda of at least 1,212 patent applications in 53 countries, regions and territories. This stream of follow-on patents could help Merck stifle competition and maintain high prices — and billions of dollars in revenue — for 14 years after its original patents expire in 2028.
- Merck has promoted a higher dosage of Keytruda than is necessary, some leading cancer researchers say. And that dosage could cost the world an estimated $5 billion just for lung cancer patients by 2040, according to researchers at the World Health Organization.
- The drug giant has taken advantage of industry regulatory shortcuts, helped orchestrate a costly global lobbying campaign and operated with a gross lack of transparency in pricing. It has distributed tens of millions of dollars in the U.S. in consulting fees, travel costs and other Keytruda-related payments to doctors and health-care professionals.
All of these strategies produce revenue for Merck, with about 60% of its Keytruda sales in the U.S.
An ICIJ analysis shows that Merck has generated about $163 billion in Keytruda sales since 2014, reaching more than 3 million people. The company funneled nearly $75 billion in dividends to shareholders and $43 billion into share buybacks while reducing its U.S. taxes by recording profits in lower-tax jurisdictions. In its 2025 annual report, Merck disclosed it paid around $1.6 billion in U.S. income taxes, compared with $4.5 billion in other countries.
Davis declined to comment for this story, but Merck senior vice president Johanna Herrmann defended the company’s pricing practices, saying that Keytruda’s price “reflects its value to patients and health-care systems.”
“We have a long history of responsibly pricing our medicines to reflect their value to patients, payers and society,” she wrote in a letter to ICIJ.
Herrmann acknowledged in a separate letter that Merck faces “increasing political and business pressures” over access and pricing in emerging markets. But she said the company is working to ensure health care is “affordable, efficient, equitable and sustainable on a global scale.”
In our reporting, we found that Merck’s conduct was typical of the pharmaceutical industry — and that the company was not an outlier in terms of its overall business practices. But the incredible growth of and interest in Keytruda could be further pushing what is acceptable by industry standards.
Peter Maybarduk, director of the access to medicines group at Public Citizen, a nonprofit consumer advocacy organization based in Washington, D.C., said the pharmaceutical industry has created a system of global rules to protect drugmakers and ensure wealthy governments protect them. “There is a whole architecture underpinning Keytruda and every patented drug where the U.S. government and Europe go to bat for the industry and its rules,” he said.
That system is marked by big questions about how the practices of Merck and the other Big Pharma companies affect the future of our collective wellness. How that plays out is often the story of putting profits over patients. For the world’s haves and have-nots, it can also be the story of who lives and who dies.
Miracle beginnings
Rob Davis, 59, grew up in Franklin, Ind., a farming town 20 miles south of Indianapolis, in the shadow of Eli Lilly, one of the world’s largest drug companies. He would work at Lilly for 14 years while studying for his business and law degrees.
When his father, Morris, an auditor, was fighting cancer, Davis went for a job interview with Merck’s then-CEO Ken Frazier. At the end of their meeting, Frazier directed Davis toward an image by the door. He wanted to show him a PowerPoint slide taped to the wall, Davis said in a 2024 interview at Northwestern University’s law school. It displayed different tumor types and their responses to Keytruda.
“This is why you need to come to Merck,” Frazier told him. “Because we’re going to make a real difference.”
Robert Davis, chief executive officer of Merck, speaks during a Senate Health, Education, Labor, and Pensions Committee hearing on drug prices in Washington, D.C., in February 2024.
Davis joined Merck as chief financial officer in the spring of 2014, a few months before his father died of lung cancer at age 82. “I wonder what would have happened if that drug would have been available 10 years ago when my father was going through his battle,” he said in the interview.
As Davis settled into the new job, Merck was getting ready to launch Keytruda to treat melanoma, the deadliest form of skin cancer. Projected U.S. sticker price: about $12,500 a month, or $150,000 a year.
When it emerged, it revolutionized cancer treatment. In a class of immunotherapy drugs called immune checkpoint inhibitors, Keytruda shifted the focus from directly attacking tumors to empowering the immune system to fight them. Now approved in the U.S. to treat 19 types of tumors, including of the skin, lung, breast and colon, it has become a lifeline for millions, turning previously terminal forms of advanced cancer into manageable diseases and increasing survival rates for others with cancers that are hard to treat — sometimes for months, sometimes for years.
Carolina García Corsini, right, with her daughter, Cristina in 2023. Carolina was pregnant with Cristina when she was diagnosed with cancer, but went into remission after successful treatment with Keytruda.
“All these years later I haven’t stopped coming here to give thanks, for my life, for being alive,” Carolina García Corsini told an ICIJ reporter while at a Catholic shrine in Madrid. A former journalist and mother of three from the Spanish capital, García was 37 years old and four months pregnant when she was diagnosed with metastatic melanoma in February 2011. The tumors had spread to her left breast. After securing a coveted spot in Keytruda’s first clinical trial, she began traveling to Paris every few weeks to get treated. Fourteen years later, and in remission, she said, “I’m convinced it’s a miracle.”
Such experiences are just some of the reasons Merck is now ranked No. 65 on the Fortune 500, with its Keytruda revenues greater than McDonald’s or the entire National Football League.
Today, as Merck’s CEO and chairman and head of the powerful trade lobby PhRMA, Davis promotes key pillars of the industry agenda: that patent protection and high prices help drug companies recover the billions spent developing new medicines and getting them to patients safely on a mass scale. The process typically takes a decade or more, and a U.S. patent, which generally lasts 20 years from the application date, allows companies to enjoy a dominance in the market, charge higher prices, recover research and development costs and earn profits to fund future research. From 2011 to 2023, Davis said in 2024 congressional testimony, Merck invested $46 billion to research, develop and manufacture Keytruda. He cited more than 2,200 clinical trials — conducted by Merck and other researchers — to study Keytruda, and the company plans to invest another $18 billion in Keytruda clinical studies into the 2030s.
Keytruda, known generically as pembrolizumab, is a type of immunotherapy that restores the body’s ability to fight cancer cells. Unlike chemotherapy, which targets rapidly dividing cancer cells, Keytruda disrupts a process that allows some cancers to circumvent the immune system.
That process involves a protein called PD-1, which is found on the surface of some white blood cells. (White blood cells regulate the body’s immune response.) But some cancer cells express proteins called PD-L1 or PD-L2 that bind to PD-1 and block the body’s ability to recognize and kill cancer cells.
Keytruda works by attaching to PD-1, preventing it from interacting with the cancerous cells’ proteins and allowing the immune system to detect and attack the cancer.
Pembrolizumab was first invented in the early 2000s by Dutch scientists working for a company that was later acquired by Merck. The drug was approved for medical use in the U.S. in September 2014.
But a new analysis by Public Eye, a Swiss-based nonprofit advocating for corporate accountability, estimates Keytruda’s R&D costs at $1.9 billion — 1% of the drug’s global revenue since its launch in 2014. Adding the cost of failed clinical trials, the R&D estimate is $4.8 billion, or 3% of the drug’s revenue. Patrick Durisch, Public Eye’s pharma specialist, said he based his numbers on a review of Keytruda clinical trials and their average costs, which are the largest share of R&D expenses.
Davis’ figures are “absolutely unverifiable,” Durisch told ICIJ. “Merck could throw any figure they want — as high as possible to justify the exorbitant price tag.”
“The share of R&D costs in relation to the price of a vial is very tiny and they have long been recouped,” he added. “The price is thus excessively high, not to cover the R&D costs or hedge risks but to make maximum profits.”
Nathan Cherny, an oncologist and director of cancer pain and palliative medicine at Shaare Zedek Medical Center in Israel, said a “perfect storm” led to the high cost of Keytruda. It began in 2003 when the U.S. Congress passed a “non-interference” clause as part of the Medicare law, requiring the government to go along with manufacturers’ list prices for new drugs without any price negotiations. Although the clause barred the federal government from negotiating prices, its supporters framed it as a reinforcement — not a suspension — of market forces by shifting negotiating power to private plans rather than the government.
“It was a suspension of market forces,” Cherny told ICIJ. And its impact was felt worldwide.
A ‘Wild West’ of drug development
The Keytruda promotion campaign was in its second year when an extraordinary development led to a public relations bonanza. In 2015, Jimmy Carter’s doctors used Keytruda successfully to treat the former U.S. president’s lethal skin cancer, which had spread to his liver and brain when he was 91. Patients clamored for “the president’s drug.” And Carter lived to 100.
Former President Jimmy Carter, pictured here in 2023 at age 99, boosted Keytruda’s public profile after his successful treatment for cancer when he was 91 years old.
For Keytruda’s business plan, Merck relied on strategies straight out of a pharma playbook that took hold in the United States and spread internationally. It used taxpayer-funded research, confidential pricing strategies and regulatory shortcuts, which allowed Merck to gain earlier market entry and sell Keytruda at high prices — even before full clinical evidence was available. Merck said Keytruda received 19 accelerated approvals in the U.S — under a special regulatory program designed to expedite development of new drugs for serious or life-threatening conditions. But this type of approval faces controversy because of how early the drugs enter the market, their frequently high costs and sometimes weak clinical evidence. Merck, for example, withdrew two Keytruda treatments that won accelerated U.S. Food and Drug Administration approval, because they failed to produce sufficient benefits. Merck insists it has been judicious in its use of the program.
Our investigation also shows how Merck took advantage of the orphan drug designation, a category that gives incentives to companies to develop drugs for rare diseases. Merck gained nine separate orphan designations for Keytruda.
Another Merck practice that is expanding globally is funding patient groups that advocate for insurance coverage, lobby governments and support faster regulatory approvals. Merck also pours money into payments for doctors and other health care professionals. In the U.S. alone, records show, Merck spent nearly $52 million on Keytruda-related fees to health care professionals from 2018 to 2024, with five doctors receiving more than $1 million apiece.
Merck has said that these types of payments help inform the health care community about Keytruda, which in turn improves patient care. But a U.S.-based study performed for the National Bureau of Economic Research found that prescribing physician-administered cancer drugs like Keytruda increased by 4% in the 12 months after a health care professional received funds from a drug company. Those payments — covering meals, travel, research, consulting, and speaking fees — led to more spending by doctors on cancer drugs but no improvements in patient survival, the study found.
The payments to patient groups were no less notable. In the U.S., Merck paid tens of millions of dollars to patient advocacy groups between 2017 and 2025. In Belgium, the newspaper De Tijd discovered that a dozen patient groups and cancer care advocacy organizations received about $1.8 million from Merck’s Belgian subsidiary between 2022 and 2024. Some of them also lobbied for positions aligning with the company’s push for expanded patient access to its cancer drugs and additional public subsidies. In response to questions from De Tijd, several organizations insisted they work independently of pharmaceutical companies and do nothing in exchange for their financial support.
Merck defended such practices. “We are explicit that any collaboration or funding involving patient organizations is entirely independent of health technology appraisals and could not be construed as an inducement to prescribe, recommend, or appraise a medicine,” the company said in a statement to ICIJ.
By 2021, senior scientists inside the FDA were voicing concern about the explosive growth in immunotherapy, dominated by Keytruda. Richard Pazdur, then head of the FDA’s unit working to improve the development of cancer drugs, and Julia A. Beaver, then the FDA’s chief of oncology, wrote in the New England Journal of Medicine in December 2021 that “The unbridled and rapid growth of checkpoint inhibitors has led to a Wild West of drug development, featuring a stampede of commercial sponsors, clinical trials and redundant development plans.” They decried the increasingly crowded and frantic market that, in their view, led to too many clinical trials, redundant treatments, inefficient use of resources and too many diagnostic tests to select patients.
Immunotherapy, while offering life-changing and sometimes miraculous results for a small number of cancer patients, failed to help many others, and some complained that doctors downplayed risks.
Keytruda sales ballooned globally. From 2020 to 2024, according to exclusive sales data shared with ICIJ by IQVIA Institute for Human Data Science, there was a 232% increase in France to $2.8 billion; 265% in Brazil to $753.7 million; 491% in Mexico to $137.3 million; and 584% in Türkiye to nearly $100 million.
The changed landscape raised new questions for oncologists and insurers: Which treatments work for which patients? What are the proper doses, frequency of treatment and duration of treatment? And how should they assess the value of all the new treatments?
Wolf-Dieter Ludwig, an oncologist who chaired the German Medical Association’s drug commission for 18 years, cited Keytruda as an example of “where too much money is being spent in our health care system.” The medicine has made a significant difference in some types of cancers, he told ICIJ’s partners at Paper Trail Media, but added that it rarely leads to a cure, and the high price is not justified. Pharmaceutical companies often use the term “game changer,” Ludwig said, but it is, above all, about one thing: good marketing.
Extreme prices, extreme secrecy
Keytruda’s rapid revenue growth was ultimately due more to the rising number of patients treated and prescriptions filled than to an increase in prices, according to an analysis performed for ICIJ. Pharmaceutical spending, fueled by drugs such as Keytruda, reached record highs in the 2020s. Merck says it prices its products differently across markets, and sometimes within markets, to ensure they reach as many patients as possible.
But as the global crisis over skyrocketing drug prices intensified, Davis expressed concern about cancer patients’ financial hardships. And there had been plenty of hardship. Since Keytruda came to market in 2014, ICIJ found 632 cases in which patients in 51 countries turned to GoFundMe and other crowdfunding sites to raise money for Keytruda treatments.
“We need to focus efforts on reducing out-of-pocket cost,” the Merck chief executive told investors at a health care conference in 2021. “That is the focal point.”
ICIJ’s investigation found that Merck’s list prices, or the initial undiscounted prices, vary wildly across countries, ranging from about $850 for a single 100 mg vial in Indonesia to $6,015 for the same vial in the U.S.
Cancer patients in a clinic in Quetzaltenango, Guatemala, receiving treatment.
Extreme disparities stem from secret discounts and rebates applied to list prices in different countries as well as the different ways health care systems decide drug costs. There’s no price cap for most prescription drugs in the U.S., for example, where drug manufacturers set prices largely on their own. In many other countries, governments negotiate with drugmakers to set a price.
A common feature of drug-pricing systems worldwide: They thrive on secrecy. At least half a dozen authorities around the globe refused to disclose to ICIJ and its media partners public spending details about Keytruda or the number of patients receiving the medicine. They cited an array of explanations — for example, that they or Merck had deemed the information a “trade secret.”
Despite the extreme secrecy, ICIJ obtained and compared Keytruda list prices and the drug’s maximum sales prices in 31 countries. ICIJ found big differences in affordability, with Keytruda comparatively less affordable in poorer countries. In South Africa, for example, Keytruda’s list price (excluding taxes and fees) is about $3,800 for a 200 mg dose — a third of the U.S. list price. Still, Keytruda is far less affordable in South Africa, where a person earning the median income can’t even buy one dose in a year, while in the U.S. a patient earning the median income can afford fewer than five doses.
At the same time, according to ICIJ’s analysis, Americans with the median income can afford less Keytruda than those earning the median income in some wealthy European countries, such as France and Belgium. In poorer Eastern European countries like Bulgaria and Hungary, Keytruda tends to be less affordable than in more affluent Western Europe, ICIJ’s affordability comparison shows.
And in Mexico and several other Latin American countries, sticker prices for Keytruda tend to be higher — when adjusted for economic levels — than in wealthier countries, ICIJ’s investigation shows.
In Guatemala, Alberto Xum thought, like many cancer patients in Latin America, that he would have to forgo treatment altogether. A one-year supply of Keytruda vials costs $180,000 or more in the Central American country, and Xum, a 65-year-old uninsured artisan, sells leather souvenirs in a region where the average monthly household income is around $700. Diagnosed with metastatic kidney cancer in 2022, Xum told his oncologist, Julio Ramírez, that he was ready to give up treatment after being prescribed pills that cost $1,900 every three months. Xum was able to pay just one time.
Alberto Xum, 65, said he couldn’t afford treatment after he was diagnosed with cancer in 2022. But he got lucky — a government program paid for Keytruda for him.
“I told the doctor I couldn’t afford it,” he said. “I was putting my life in God’s hands.”
To Xum’s great fortune, though, Ramírez was about to receive authorization from the health ministry for one of the first Keytruda treatments at his hospital. Xum was the chosen one. Every three weeks for the next two years Xum rode a bus for 2½ hours from his rural town, Samayac, to the public hospital in Quetzaltenango to receive the $11,000 infusion, paid for by the government.
“Sometimes I ask, ‘Who am I to deserve all this luck?’ ” Xum told ICIJ. His tumors had shrunk, but he was not in remission.
Now a new study supports ICIJ’s findings and raises fresh concerns about Keytruda’s affordability and access. Treatment for six months of Keytruda for head and neck cancer costs nearly 80 times the average monthly income in India and 43 times the average in Pakistan. The cost remained catastrophically high in wealthy countries too — nearly six times the average monthly income in the U.S. and nine times the average in the U.K., according to the study, published in February in an oncology specialty journal. In short, six months of Keytruda ranges from $7,676 in Bangladesh to $38,254 in Australia, the researchers found, concluding, “Modern immunotherapies remain economically inaccessible across most settings.”
ICIJ found Keytruda treatment costs for patients are particularly chaotic in the U.S. Data compiled by Serif Health, a San Francisco firm that analyzes health care reimbursement information, shared data with ICIJ showing that patient and insurer costs vary dramatically. Across the U.S., estimated costs range from $5,858 to $43,800 for a typical 200 mg Keytruda treatment, depending on where the drug is given, which commercial insurance company and provider are involved and how it’s billed.
For Barbara Thornton, a 64-year-old home health aide from Cincinnati, Ohio, who recently overcame pancreatic cancer, Keytruda treatments at a nearby hospital’s outpatient center cost well above the list price.
Each treatment at the infusion center came with a bill of about $42,000, Thornton told ICIJ’s partners at USA Today. A combination of her husband’s insurance, financial assistance from her hospital system, and Medicaid covered the majority of her portion of the costs.
“I was lucky. I had insurance,” Thornton said. “We’re not living the high life — let me put it that way — so we qualified for financial assistance.”
Barbara Thornton received multiple Keytruda infusions to help treat her pancreatic cancer.
Thornton received Keytruda intravenously for 27 months. When her treatment ended, she rang the bell at her center last December, marking the milestone and her transition to cancer survivor.
The Health Care Cost Institute, a nonprofit group that analyzes employer-sponsored insurance claims in the U.S., also reviewed U.S. Keytruda treatment cost data for ICIJ, covering five years from 2018 to 2022. HCCI unearthed a startling fact: In 2022, employer-sponsored insurance plans paid $3.79 billion for Keytruda coverage for just 30,997 patients – or about $122,400 per patient. The institute also found that in the same year, the cost could nearly double when Keytruda was administered in a hospital outpatient department instead of a doctor’s office.
“Whether it is drug administration, lab testing, or imaging, the care provided is often identical, but as we saw with Keytruda, the price tag depends entirely on the building you’re treated in,” said John Hargraves, HCCI’s managing director of data strategy and analytics. He added that spending nearly $3.8 billion on fewer than 31,000 patients underscores how expensive these therapies have become and how much they can drive overall spending in employer-sponsored insurance. “While it’s not unusual for specialty drugs like Keytruda to carry very high per-patient costs, the scale of spending we’re seeing here is remarkable and raises important questions about affordability for employers and patients alike,” Hargraves said.
In a statement, Merck spokeswoman Julie Cunningham blamed high prices in the U.S. on pharmacy benefit managers and health insurers, middle players who extract rebates and fees, driving up costs for patients. “Narrowly focusing on prescription drugs fails to address the much bigger contributors to higher health care spending in the United States,” Cunningham said. “America is the only country in the world where entities that don’t make medicines take half of every dollar spent on brand medicines.”
Merck’s Herrmann said 59% of U.S. patients with private health insurance paid no out-of-pocket costs for Keytruda. For those patients with out-of-pocket costs, about 80% paid between 1 cent and $375 per infusion, after satisfying their deductible. “We routinely provide coupons and other co-pay assistance for our products, including Keytruda, to reduce out-of-pocket costs,” Herrmann said, adding that the value of this assistance totaled around $125 million last year. But even when insured, patients may struggle with thousands of dollars in upfront costs, including high deductibles before coverage kicks in.
Merck’s U.S. headquarters in Rahway, New Jersey.
Although the company does not publicly break out how much it spends on patient assistance for Keytruda, Herrmann said Merck provided $1.7 billion in free medicines in the U.S. — covering all eligible Merck products — to uninsured or underinsured patients in 2024.
For Nasır Nesanır, chair of the public health branch of the Turkish Medical Association, these disparities are framed by larger questions that go beyond health care.
“Should medical innovation be regarded as a common gain of humanity?” Nesanır asked in an interview with ICIJ partner DW Türkçe in Türkiye. “Or should it remain a commercial asset under patent protection that deepens global inequality?”
Put another way: Is the system designed around saving lives first or making money — and who gets left out because of that choice? The answers aren’t just about health care but speak to larger debates about whether lifesaving discoveries belong to all of us.
‘How devastating it is for them’
In Mumbai, India’s wealthiest city, where more than half the population lives in slums or extreme poverty, 101 patients and their families wait in the hallway outside the oncology clinic of Nair Hospital for their appointments with Amol Akhade, a prominent oncologist. He sees India becoming the “cancer capital of the world” because of its skyrocketing number of cases fueled by rampant tobacco use and poor diet. And then there is this challenge: One month of Keytruda can equal more than 12 months of wages in the country, one survey showed.
Akhade gestures toward the crowded outpatient hallway as a reporter for ICIJ’s media partner The Indian Express shadows him on this early Wednesday morning. “In the crowd of 100 patients that you see outside this ward right now, nearly 70 patients with solid tumors could have significantly benefited from Keytruda,” he says. “However, right now we are unable to even discuss this treatment option with them because it is simply unviable for them.”
“They are hand-to-mouth daily wage workers,” Akhade told ICIJ. “They are worried about where their next meal will come from.” The Indian government provides chemotherapy to these patients for free, however. Others receive help from Merck’s patient assistance programs. In India, the program is called Kiran, a Sanskrit-derived name meaning “ray of light,” which lets patients buy five vials and get up to 30 free, according to reporting from the Indian Express. Merck says Kiran has provided access to Keytruda to more than 68,000 patients across 11 Asia-Pacific markets and is committed to expanding that.
Patients waiting to be seen at Nair Hospital in Mumbai, India.
“The company is doing their bit to make the drug affordable,” Akhade said. “It is not like they’re doing nothing. But it’s still very difficult for most patients. They can do more. They can definitely do more.”
A top oncologist at Tata Memorial Hospital, less than three miles from Nair Hospital, agrees. “It is heartbreaking and disheartening for us,” Kumar Prabhash told ICIJ. “And now let us think from the patient point of view how devastating it is for them.”
Prabhash, a professor who leads the hospital’s oncology unit, and colleagues in Mumbai and Delhi are working on cost-effective ways to expand access. Although Merck recommends 200 mg of Keytruda every three weeks, doctors at Indian hospitals are testing low-dose immunotherapies. In one clinical trial, breast cancer patients received three doses of Keytruda at 50 mg every six weeks along with chemotherapy. In other studies, patients received low dosing or weight-based dosing of Keytruda — 2 mg per kilogram every three weeks or 1 mg per kilo every six weeks.
So far, results from the trials indicate that lower doses of Keytruda are effective for some types of treatments. Hospitals in Singapore, Malaysia and Taiwan have arrived at a similar conclusion from their own studies, and several countries — including the Netherlands, Canada and Israel — have started switching to weight-based dosing.
The health system just simply cannot afford all of these drugs. — oncologist Daniel Goldstein
The savings can be massive. After years of studying the costs and benefits of cancer drugs, Daniel Goldstein, a British-born oncologist with U.S. training now practicing in Israel, made that discovery in 2017: Fixed dosing of Keytruda costs the U.S. health care system an extra $825 million annually. “The health system just simply cannot afford all of these drugs,” Goldstein, director of the Center for Cancer Economics at Rabin Medical Center’s Davidoff Cancer Center, told ICIJ. “And in every single country in the world, there’s pressure.”
Researchers for the World Health Organization estimated in a separate, modeled projection that the world could save $5 billion over 15 years if lung cancer patients received Keytruda based on their weight vs. fixed-dosing amounts. And the weight-based dosing method would be more of a savings for all eligible cancer patients.
Merck said it bases its dosing formulas on clinical evidence detailed in the FDA-approved recommended dosage section of its Keytruda prescribing information. But Goldstein’s crusade gathered momentum and spilled beyond borders. Bishal Gyawali, an oncologist and drug policy researcher in Canada, told ICIJ’s partners at the Toronto Star of a key reason Merck likely gives the same dose to everyone: money. “They can sell more of the drug,” he said, and “they will make more money. … There is no scientific, medical, biological reason to do that. It’s just commercially motivated.”
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‘A potential landmine’
Hoping to protect and nurture its golden goose, Merck stayed focused on the No. 1 way it knew to maintain high prices: the global patent system. Keytruda’s primary patents were set to expire in 2028, and investors worried about how Merck would generate revenue after Keytruda lost its protected monopoly. That loss of exclusivity would open the floodgates to rivals offering sharply lower prices, with Keytruda facing a catastrophic decline of revenue — a $35 billion patent cliff.
To keep that from happening, Merck deployed its army of lawyers. Tahir Amin, founder of the Initiative for Medicines, Access and Knowledge (I-MAK), a nonprofit group that examines inequities in how medicines are developed, called Merck’s strategy a “multi-pronged patent abuse scheme” to prolong its monopoly and maintain high prices.
Merck says I-MAK and “similar organizations” propagate a myth that pharmaceutical companies “game the patent system” by filing multiple overlapping patents to inappropriately delay entry of generic or biosimilar drugs. The company also claimed I-MAK’s reporting has serious errors in the cataloging and description of Merck’s patent practices, an accusation denied by I-MAK.
When ICIJ mapped Keytruda’s patent landscape, it found 1,212 patent applications related to the drug filed by Merck and other cancer research businesses. They span 53 countries, regions and territories, including 194 applications in the U.S., 123 in Japan, 87 in Australia, 80 in China and 74 each in South Korea and Canada. This patent wall has allowed Merck to use strategies common in the industry to keep the price high through additional patents beyond 2028. ICIJ found 211 granted patents that help protect Keytruda’s dominance through at least 2042, which will be 14 years after the original U.S. patents expire. ICIJ also identified at least another 337 “pending” patents that, if granted, could extend the drug’s reign even longer. Eighty-four percent of all these patent applications came after Keytruda’s 2014 approval.
“Each patent application is a potential landmine” that could create a costly and lengthy legal challenge for Merck’s lower-cost competitors, Amin told ICIJ. “The goal is to carpet-bomb the competitor with as many patents as possible to either deter them, make the cost of entering [the market] as costly as possible or hope the more patents a competitor has to litigate their way through will result in a settlement” that could mean a delayed launch.
But Merck says its post-2014 patents are genuinely new discoveries. “We continue to evaluate Keytruda in the hopes of expanding its use to other forms of cancer and increasing access to the treatment,” Herrmann said in a letter. “This includes innovations around formulation, dosing and novel uses, including combinations with other agents. As you would expect, when appropriate, Merck protects its innovation through the filing of patent applications.”
Merck’s scramble to fortify its dominance includes filing for patents that are combinations of Keytruda and another medicine. For example, ICIJ identified 29 patent applications filed jointly worldwide by Merck and Japan-based Eisai relating to the combination therapy of Keytruda with the cancer drug Lenvima. But according to Amin, this type of combination is not new.
“Why is Merck not exploring new, unchartered therapeutic combination avenues?” Amin asked. “What is the point of dedicating time and money towards therapeutic combinations that already exist?”
Merck engineered another patent strategy commonly used by drugmakers. It filed new patents for a “product hop” — switching consumers to a similar, newer version of the same drug that resets the patent clock for more years of exclusivity. Merck hopes to move up to 40 percent of its customers to a Keytruda injection given under the skin instead of an intravenous infusion before lower-cost rivals gain a foothold. The product hop could help Merck generate billions of dollars and delay competition into the 2030s, according to three industry experts.
And Merck adopted a new pricing tactic in Latin America in 2024, when an Argentine firm tried to shake up the market with a local, cheaper version of Keytruda called PembroX. Merck had no patent in force in Argentina, where there is chronic economic turbulence and a hostile environment for foreign drug companies. The New Jersey firm was operating alone in the market, constantly raising prices, Gustavo Pelizzari, CEO of the rival drug company Elea, told ICIJ’s Argentine partners. PembroX went on sale in January 2025; the day before the launch Merck suddenly lowered its price for Keytruda by 50%, just marginally higher than the competitor’s price, Pelizzari said. And Keytruda’s price kept dropping.
The competition has led to wider access and affordability, Pelizzari said, with thousands more patients now being treated. That led him to consider Keytruda’s pricing and its financial impact in the U.S.
“I’m convinced that they’re selling much cheaper in Argentina than in the United States,” Pelizzari said. “They must be causing significant damage to the American government. I mean, they, Merck,” he said, “should be forced to sell at the Argentine price. That’s why they don’t make the prices public.”
Price explosions
Merck’s Rob Davis experienced a wave of online hate after he expressed condolences and sadness for Brian Thompson, the CEO of UnitedHealthcare who was fatally shot outside a Midtown Manhattan hotel in December 2024. In addition to the shock and condemnation, the early morning killing also unleashed widespread celebration and declarations of justice from patients all over the world who had experienced denied insurance claims.
“Saddened?” a cancer patient wrote on Davis’ LinkedIn account. “Does your sorrow extend to the patients and families who have lost their lives or livelihoods because of leadership and policies prioritizing profit in insurance over health?”
Given the disquieting endorsement of Thompson’s assasination in the days that followed, every CEO in the health care industry could be justified in feeling anxiety. But Davis was dealing with additional pressures: While Keytruda’s patent expiration was still four years off, investors were already bracing for the impact. With the new U.S. president touting lower drug prices on the campaign trail, what would that mean for Merck and Keytruda?
Protestors demonstrated against healthcare companies’ profiteering outside the trial of Luigi Mangione, who is accused of killing of UnitedHealthcare CEO Brian Thompson in New York in 2024.
“So lots of concerns about Keytruda,” said Tim Anderson during an earnings conference call in April 2025. Anderson was a stock analyst at Bank of America at the time and was worried about Merck’s stock dropping. He added that he’d raised these concerns last quarter as well. Now, Anderson asked Davis, “I’m wondering where you are on that line of thinking as the stock continues to kind of drift lower.”
Merck was confident, Davis replied, about the future revenue stream. “We have over 20 new products that we see coming over the next few years,” he said, “almost all of which have blockbuster potential.”
Merck paid PhRMA $16 million in 2024 to lobby on its behalf, and Davis, following in the footsteps of his predecessor, became chairman of the trade group’s board in February. PhRMA explicitly asked U.S. officials to target European drug policy and take action against countries trying to control prices of Keytruda and other branded drugs. Among the nations singled out were Australia, Canada, Denmark, France, Germany, Greece, Italy, Japan, South Korea, Spain, Switzerland and the United Kingdom.
At a conference in Paris in February, Belgium’s deputy prime minister and health minister, Frank Vandenbroucke, detailed the “squeeze” to raise prices. “The Trump administration is prepared to use trade coercion to force European governments to change their pricing practices,” Vandenbroucke said. He cited Trump’s claim in January that he had pressured President Emmanuel Macron to raise French drug prices by threatening 100% tariffs on champagne.
After months of pressure from the White House, Davis joined executives from 15 pharmaceutical companies in endorsing deals with Trump to sell medications for less in the U.S. Davis and Trump shook hands, and the president vowed to lower prices to what’s paid in other wealthy countries.
Neither the Trump administration nor the manufacturers would disclose details of the agreements. Merck wouldn’t say whether Trump carved out an exemption for Keytruda, but health policy researchers and government sources said it’s not clear the price of Keytruda will go down in the U.S. anytime soon. Prices could climb elsewhere, though, as they already have in the United Kingdom, or as they could in Germany, where an industry source sees “price explosions.” And, said Peter Maybarduk, the consumer advocate, “In poor countries, all Trump’s plans may achieve is more suffering and death.”
U.S. President Donald Trump shakes hands with Merck CEO Robert Davis during the December White House announcement about lowering prescription drug costs.
Promises and prescriptions
In February, Trump used his State of the Union address to give a pep talk about the slowing U.S. economy. “Our country is winning again,” he said. “In fact, we’re winning so much that we really don’t know what to do about it.”
“I took prescription drugs, a very big part of health care, from the highest price in the entire world to the lowest,” Trump said. “The result is price differences of 300, 400, 500, 600% and more” — claims the administration has provided no evidence for.
There was no mention of Keytruda. In fact, Trump spent just five minutes of the 1 hour 47 minutes — the longest State of the Union address in history — talking about health care costs. He spent more time celebrating the U.S. men’s hockey team.
Nearly 3,000 miles away in Guatemala, the contrast to Trump’s grand promises for affordable health care felt a world away. At sunrise on a cold Friday in February, Julio Ramírez, the oncologist who treated Alberto Xum, walked through the small waiting room at his public hospital’s oncology unit, greeting everyone on the way to his office, where he sees about 40 patients a week.
Oncologist Julio Ramírez works at the public hospital in Quetzaltenango, Guatemala, where access to Keytruda is limited.
Ramírez showed an ICIJ reporter handwritten lists of medications he needs for his patients. He knew he wasn’t likely to get them all because of budget constraints.
“Look, I’m not complaining,” he said. “I have the opportunity to give [Keytruda] at least to two or three patients here at the hospital” — an uptick in what he had previously been able to offer.
“My dream would be to be able to give all my patients the prescriptions they need without having to play Eeny, meeny, miny, moe to decide who gets it and who doesn’t,” he said.
It was time for the doctor to start seeing the day’s patients. A short, middle-aged man, wearing a face mask and ski cap, moved quietly toward the office, clutching his latest test results. Ramírez shook the man’s hand, and then he got down to the business of what he could — and couldn’t — do for him.
Editor’s note: Some ICIJ funders advocate for reform of the pharmaceutical industry to make it more transparent and its products more affordable and accessible for patients. Funders have no involvement in ICIJ’s editorial decisions.
Contributing reporters: Andrés Bermúdez Liévano, Iván Ruiz (CLIP); Hala Nasreddine (DARAJ); Lars Bové (De Tijd); Zsuzsanna Wirth, Zita Szopko (direkt36); Pelin Ünker (DW Türkçe); Sergio Silva Numa (El Espectador); Carlos Carabaña, Daniele Grasso (El País); Gaby de Groot, Thieu Vaessen (Het Financieele Dagblad); Mariel Fitz Patrick (Infobae); Shauna Bowers (Irish Times); Jiyoon Kim (KCIJ-Newstapa); Kristof Clerix (Knack); Gloria Riva, Leo Sisti (L’Espresso); Francisca Skoknic (LaBot); Hugo Alconada Mon (La Nación); Natasha Cambronero (La Nación); Anne-Sophie Leurquin (Le Soir); Yiswaree Palansamy (Malaysiakini); Jacob Borg (Malta Times); Dejan Milovac (MANS); Maria Christoph, Sophia Stahl (Paper Trail Media); Jody García (Plaza Pública); Guilherme Waltenberg (Poder360); Stefan Melichar (profil); Despina Papageorgiou (Reporters United); Violeta Santiago (Quinto Elemento Lab); Fabiola Torres (Salud con Lupa); Fiona Walker, Andjela Milivojevic (The Bureau of Investigative Journalism); Nayonika Bose, Anonna Dutt, Kaunain Sheriff (The Indian Express); Amy Dempsey, Jesse McLean, Megan Ogilvie (Toronto Star); Jacob Borg (Times of Malta); Dirk Waterval, Martijn Roessingh (Trouw); Austin Fast (USA Today); Kirsi Karppinen, Minna Knus-Galán (Yle); Denise Ajiri, Agustin Armendariz, Jelena Cosic, Isabella Cota, Jesús Escudero, Miguel Fiandor Gutiérrez, Karrie Kehoe, Micah Reddy, Delphine Reuter, Joanna Robin, David Rowell, Richard H.P. Sia, Dean Starkman, Fergus Shiel, Annys Shin, Angie Wu (ICIJ)
