An Ontario oncologist can arrange a prescription for a cancer immunotherapy that costs the health-care system $15,000 a month with three clicks of a mouse. In Nepal, where Dr Bishal Gyawali was born and trained, 95 per cent of the population cannot afford the same treatment. Meanwhile, counterfeit Keytruda has reached hospitals in Mexico and been sold to patients in India, with at least one patient reported to have died after receiving a fake dose.
These stark contrasts emerge in Cancer Calculus, a yearlong investigation by the Toronto Star and the International Consortium of Investigative Journalists (ICIJ), published Sept. 13, 2026. The project involved 46 media partners across 37 countries and examines how the high cost of Merck & Co’s blockbuster drug, coupled with weak health systems, is determining which patients receive potentially life-extending treatment.
A breakthrough with radically different reach
For Gyawali, a medical oncologist at Kingston Health Sciences Centre and a professor in Queen’s University’s department of cancer care and epidemiology, the administrative barrier in Ontario is remarkably low.
“With three clicks of a mouse I can make it happen,” Gyawali said. “I can easily prescribe a drug that costs the health-care system $15,000 a month.”
He has no quarrel with that ease of access. Pembrolizumab, sold as Keytruda, is an immunotherapy that has changed the outlook for some people with cancer, extending survival by years in certain circumstances. Gyawali calls these treatments “true game changers.”
The difficulty is that the benefits are not distributed evenly. Keytruda generated more than $30 billion in revenue last year, yet access remains out of reach for many patients in lower-income countries. The investigation found that patients, clinicians and families are often forced to navigate unaffordable prices, fragmented reimbursement systems and, in some places, treatment facilities that lack the infrastructure needed to deliver the drug safely.
The price of a year of treatment
In Canada, the list price for a 100 mg vial is $4,400 Canadian, according to Canada’s Drug Agency. At that figure, a year of Keytruda carries an estimated sticker price of $150,000, although experts say the price actually negotiated with the manufacturer would be lower.
The gap is far wider elsewhere. In Brazil, the world’s sixth most populous country, most cancer patients cannot afford Keytruda, and thousands have turned to the courts in attempts to obtain it. In South Africa, where most citizens cannot afford private health insurance and a typical household earns less than $500 a month, one dose costs roughly US$4,90