Published Mar 11, 2026 | 12:22 PM ⚊ Updated Mar 11, 2026 | 12:22 PM
Clinical gains from immunotherapy in head and neck cancer are real and also modest. Credit: iStock
Synopsis: A new study highlights the catastrophic unaffordability of immunotherapy for head and neck cancers in India and other countries. Six months of pembrolizumab costs nearly ₹61 lakh in India — 80 months of a teacher’s salary. Even cheaper options like nivolumab remain out of reach. Researchers urge prevention, early detection, and generics to counter unsustainable costs.
A schoolteacher in Chennai earns around ₹25,000 a month. She teaches, saves, pays rent and feeds her family on that. Then one day a doctor tells her she has head and neck cancer and prescribes pembrolizumab, one of the newest immunotherapy drugs, as her best option.
Six months of that treatment, according to a study published in the journal Head & Neck, would cost her approximately ₹61 lakh at today’s exchange rate in India. That is nearly 80 months of her salary, paid before any other bill, any rent, any food.
The cheaper immunotherapy on the list, nivolumab, would cost her around ₹5.5 lakh for the same six months. Still 22 months of salary. Still beyond the reach of most Indian households.
Researchers compared the cost and affordability of five drugs used to treat recurrent and metastatic head and neck cancers across seven countries: India, Pakistan, Bangladesh, South Africa, the United States, the United Kingdom and Australia. The five drugs were pembrolizumab and nivolumab, both immune checkpoint inhibitors, alongside the targeted therapies cetuximab, gefitinib and erlotinib.
They gathered prices from national formularies, the WHO Global Price Reporting Mechanism and health ministry databases, then measured each drug’s cost as a share of average monthly income in each country.
The results left no room for interpretation. “Immunotherapy was unaffordable across all settings,” the study said.
“Six-month pembrolizumab costs corresponded to 7,994 percent of monthly income in India, 4,311 percent in Pakistan, 3,133 percent in Bangladesh, and remained above catastrophic thresholds in high-income countries — 591 percent in the United States and 903 percent in the United Kingdom.”
Six months of pembrolizumab costs around $11,091 in India (₹10.2 lakh), $7,676 in Bangladesh, $12,675 in Pakistan, $22,565 in the UK and $33,550 in the US. The drug costs less in South Asia than in the West. But wages sit lower still, so the share of income consumed by the treatment runs in the opposite direction.
When researchers adjusted for purchasing power parity, the PPP-adjusted six-month cost of pembrolizumab in India reached the equivalent of $66,548, which at today’s exchange rate of ₹92 to the dollar converts to approximately ₹61 lakh. This exceeded a full year of per capita income.
“The rapid pace of innovation has outstripped affordability,” the authors said.
“Our study demonstrates that immunotherapy for head and neck cancers is catastrophically unaffordable across all settings studied, with 6 months of pembrolizumab and nivolumab consuming several thousand percent of monthly income in South Asia and remaining above catastrophic thresholds even in high-income countries.”
The study then asked a different question. If a health system takes the money it would spend on one patient’s six-month course of pembrolizumab and uses it instead to buy gefitinib, an older oral targeted therapy, how many patients could it treat? In India, 19 patients. In Pakistan, 22. In Bangladesh, 18.
Gefitinib does not perform as well clinically. The researchers make that clear. But in a country where over half of all healthcare spending comes directly from patients’ own pockets, the numbers describe a real choice that health systems face every time a prescription gets written.
“In resource-limited contexts, where universal health coverage is weak and over 60 percent of care is paid out-of-pocket, the high cost of immunotherapy translates directly into catastrophic household expenditure,” the authors said.
“This is not simply a health-system budgeting problem but reflects macro-political failures of financing and universal health coverage.”
The clinical gains from immunotherapy in head and neck cancer are real and also modest. In the CheckMate 141 trial, nivolumab extended median overall survival by around two to three months compared with standard therapy in patients with recurrent disease. Pembrolizumab showed survival benefit in first-line treatment but produced little change in progression-free survival.
“While immunotherapy represents an important advance, its benefits may be incremental, and its costs — regularly exceeding annual household incomes in low- and middle-income countries — can make it economically unsustainable,” the authors said.
UK’s National Institute for Health and Care Excellence assesses immunotherapies against a threshold of £20,000 to £30,000 per quality-adjusted life year. Drugs that exceed this face restricted indications, conditional approvals or placement in a Cancer Drugs Fund. Canada conducts similar reviews and regularly recommends price reductions before granting access.
“These mechanisms reflect growing recognition in high-income settings that unconstrained adoption of high-cost immunotherapies is fiscally unsustainable, even where universal coverage exists,” the study said.
In the US, insurance softens the cost but does not eliminate it. Co-payments and financial toxicity occur across income levels. Even insured American patients carry a portion of a price that the study calculates at 591 percent of average monthly income for six months of pembrolizumab.
Head and neck cancers in India connect directly to tobacco, betel quid and alcohol. They also connect to late diagnosis, because patients reach a hospital after disease has advanced past the stage where surgery or radiotherapy could still control it at lower cost and higher success. The researchers cite estimates from their own institute of billions of dollars in productivity lost to oral cancer in India through premature deaths and disability.
“Prevention and early detection should be seen not only as health priorities but also as economic imperatives,” the authors said. “The costs of unchecked incidence borne by patients, families and national economies far outweigh the incremental benefits delivered by high-cost systemic therapies.”
The authors identify one path that could shift the equation: generics and biosimilars manufactured at scale and priced to break the hold that Western pharmaceutical markets keep over immuno-oncology. They describe incremental price concessions as insufficient.
“Unless drug prices fall dramatically or generics become widely available, modern immunotherapies will remain economically inaccessible for most patients in developing countries,” the authors said. “The current system needs fundamental change.”
The study notes its own limits. List prices overstate what some countries pay once confidential discounts enter negotiations. But the researchers observe that lower-income countries typically lack the power to secure those discounts. What the formulary says is what most of them pay.
