The Cancer Calculus, the latest investigation from the International Consortium of Investigative Journalists, brought together 47 media partners in 37 countries, from Finland to Brazil, India, Malta, Mexico and beyond.
The reporting shed new light on the strategies pharmaceutical giant Merck & Co., known as MSD outside the U.S. and Canada, has used to widen the use of its blockbuster cancer drug, Keytruda, and protect its monopoly. Journalists found that the drug’s sky-high price has caused a ripple effect for health care systems around the world, exacerbating inequalities and driving patients to desperate measures.
The reporting team interviewed hundreds of people, including oncologists, cancer patients and their families, patent experts, regulators and pharmaceutical industry insiders, and gathered more than 1,000 public records requests in 27 countries. Here are some of the stories our partners told around the world.
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.
Higher dosing strains public health systems
If a toothpaste maker widens the tube opening, it empties faster.
That’s how oncologist Dr. Daniel Goldstein describes the likely reason behind Merck’s move to set a fixed 200 milligram dose of Keytruda for all patients, despite originally submitting studies to regulators that used a weight-based dosing system which could recommend lower doses for some patients.
In an interview with Paper Trail Media published in German outlets Der Spiegel and ZDF, the Israel-based cancer specialist laid out his potentially game-changing research finding: Keytruda can work at 25% lower doses with identical efficacy. This would mean significant savings for insurers and public budgets around the world.
Paper Trail’s work in Austria, as published in Der Standard , shows that Keytruda costs 6,800 euros (about $8,000) per dose without discounts, making it the country’s single largest medication expense. Consulted by reporters, research and advocacy organization Public Eye calculated a fair price for the drug to be 80 euros (about $94) per dose. Austria, the reporters found, is the sole country in the European Union with no price ceiling for hospital drugs.
ICIJ’s partners’ work in both countries exposed the health system’s deeper dysfunctions beyond the strain that Keytruda purchases have on their budgets.
How competition could boost access
In January, Argentina became the sole country where a local pharmaceutical company is authorized to produce a biosimilar version of pembrolizumab, Keytruda’s active ingredient.
Reporters found the availability of an alternative slashed the cost of drug in more than half, with local company Elea offering the government a price 56% lower than what MSD had previously charged.
ICIJ partners from five different outlets, La Nación , CLIP , El diarioAR , Infobae and Ruido , found that when Elea launched its biosimilar in January 2025, retail prices for Keytruda fell sharply, and a greater number of patients gained access to the medication.
The Argentine team said their reporting highlighted a tension playing out worldwide between protecting innovation and ensuring mass access to treatments through market competition. In the rest of the world, Merck maintains a tight monopoly over the drug through patents and lobbying efforts.
MSD claims to have invested $44 billion in the research and development of the cutting-edge drug — money that a competitor like Elea doesn’t have to spend to produce a biosimilar medicine. Elea told the Argentine team of reporters that the two pharmaceutical companies had explored the possibility of forming an alliance, which ultimately did not materialize. Merck did not deny this version of events.
A ‘burgeoning black market’ in India, where counterfeits abound
At a price of 1.5 lakh rupees, or around $1,800, per vial, Keytruda is unaffordable for most families in India. That creates a strong incentive to sell counterfeits in what reporters from The Indian Express call “a burgeoning black market.”
ICIJ partners there found that a highly organized group of pharmacists and fixers were using authentic batch numbers and refilling used vials to peddle counterfeits of the drug to desperate patients.
Reporters identified multiple points in an 11-step process from prescription to delivery to disposal of the drug where a Keytruda vial could slip into the grey market — with hospital departments implicated in the corruption.
The Indian Express reported that this counterfeit system operated with impunity across some of India’s most trusted medical institutions, and found systemic failures in supply chain oversight and hospital accountability at the highest levels.
In Brazil, patients use lawsuits to gain access
Reporters at Poder360 found that patients were using a constitutional right to health in Brazil to fight for access to Keytruda, even though the drug has not yet been incorporated into the Brazilian public healthcare system or health insurance plans.
In a backdoor system that has exploded in popularity in the last thirty years, well-informed patients take their cases to court to demand coverage for high-cost treatments — and, in most cases, they succeed. The result is known by experts as the “judicialization” of healthcare, where access depends less on clinical protocols and more on the patient’s ability to navigate the judicial system.
Although patients were having success through the courts, reporters found that the process meant both potential delays in treatment as well as higher prices for the government, which was paying more for medications on an urgent basis.
One patient, Antonio Carlos Striotto Marins, told reporters how he turned to a lawsuit to obtain Keytruda after other treatments failed to stop the spread of cancer that began as melanoma but had metastasized to other organs. In the nine months it took his case to work its way through the court, the cancer spread further, reaching his lungs.
The judicialization of healthcare also creates a treatment gap between the well-connected in large urban centers and those in remote regions that lack information, access and means to reach the judicial system, reporters found.
Keytruda prescriptions lag in Finland — and so do cancer outcomes
ICIJ’s Finnish partners at Yle found that Finland uses new immuno-oncological cancer drugs significantly less than other European countries — and cancer patients die sooner, researchers said.
Part of the reason for lower use rates, experts told reporters at Yle, is the sheer cost: treatment for one patient can cost as much as $100,000.
According to the Swedish Institute of Health Economics, Finland is at the bottom of Europe in the use of those drugs, including Keytruda. And, researchers say, that low use may partly explain why cancer treatment outcomes in Finland have lagged behind those of other Nordic countries.
U.S. ambassador to Greece lobbied on Merck’s behalf
In April, U.S. Ambassador Kimberly Guilfoyle held a private meeting at her residence. She’d promised representatives of the American pharmaceutical industry in Greece that she would “nail” down the Greek government on their behalf, ICIJ’s Greek partners at Reporters United reported.
The meeting, which included Greek finance ministers and representatives of American pharmaceutical companies in Greece, was to discuss the state’s clawback scheme. For over a decade, the Greek government has required an automatic reimbursement of money from pharmaceutical companies when the state exceeds the maximum limit it set for the year for spending on pharmaceuticals.
Initially established in 2012 during the economic crisis, pharmaceutical companies and politicians have lobbied against the policy for years — and pressure to change it has ramped up during the Trump administration, the reporters found.
Cancer Calculus revealed Merck spends significantly on lobbying; in the U.S. alone, according to Reporters United, Merck paid almost $52 million in consulting fees and other payments related to Keytruda to healthcare professionals between 2018 and 2024, with five doctors receiving more than $1 million each.
The U.S. embassy did not respond in detail to Reporters United’s questions about the meeting, noting they do not comment “on the content of private diplomatic discussions” as a matter of general policy.