Essential but unaffordable: Real-world costs of WHO essential cancer medicines in a low-income setting.

1508 Background: The World Health Organization (WHO) Essential Medicines List (EML) defines priority anticancer medicines. In many low-and-middle-income countries (LMICs), EML inclusion may not translate into financial accessibility. Using Nepal as a case study, we mapped availability pathways and real-world prices to quantify affordability of WHO EML regimens. Methods: We conducted a cross-sectional audit of WHO EML anticancer medicines in Nepal. Regimens were selected for high-incidence and high-curability cancers and to reflect commonly used standard-of-care regimens. Patient prices were abstracted from Nepal distributor and manufacturer price lists (2024–2026), using the lowest listed patient price when multiple listings existed. Regimen costs were estimated using standard dosing and typical cycle numbers. Metastatic regimens were excluded because treatment duration is open-ended. Fixed-duration curative-intent regimens were analyzed. The primary outcome was affordability, expressed as regimen cost divided by annual GDP per capita (Y), used as a proxy for yearly income. Results: WHO EML drugs were broadly identifiable, but free access to high-cost agents via NGO programs was confined to three city hospitals, creating a geographic lottery. Using Y = US1, 447/year, estimated total costs for standard regimens were substantial: dd AC-T for breast cancer US552 (0. 38Y) ; FOLFOX for colon cancer US1, 226 (0. 85Y) ; CAPOX US1, 090 (0. 75Y) ; FLOT for gastric cancer US1, 063 (0. 73Y) ; and R-CHOP for lymphoma US1, 144 (0. 79Y). Add-on biologics were far higher: trastuzumab for HER2-positive therapy (17 cycles) was US3, 998 (2. 76Y). Pembrolizumab (9 cycles) was US27, 246 (18. 83Y). One year of oral targeted therapy was osimertinib US4, 448 (3. 07Y) and olaparib US10, 716 (7. 41Y). Conclusions: In this LMIC case study, most WHO EML curative regimens approached/exceeded one year of average income, while add-on components approached two decades. EML prioritization alone was insufficient to ensure financial access at the point of care. The findings support targeted national procurement with financial-risk protection for a small set of high-impact medicines, complemented by high income countries (HIC) –LMIC access partnerships, like said NGO-programs, to extend reach beyond a geographically advantaged catchment. Nepal oncology regimen costs. Regimen Cost/cycle (USD) Total treatment cost (USD) Cycles/duration Breast dd AC-T 68 551 8 dd AC-TH 235 3, 998 17 TNBC-pembro 3, 027 27, 246. 9 Colon FOLFOX 102 1, 226 12 CAPOX 136 1, 089 8 NSCLC Paclitaxel + carboplatin 119 715 6 Pemetrexed + carboplatin 78 470 6 SCLC Carboplatin + etoposide 40 245 6 EGFR TKI in NSCLC Osimertinib 4, 393 1 BRCA+ breast/ovarian Olaparib (300 mg BID assumption) 10, 716 1 Gall bladder Gemcitabine + carboplatin 108 653 6 Gemcitabine + capecitabine 145 874 6 <jats: td colspan="4"