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Mesothelioma Stage 4

Stage 4 mesothelioma is the most advanced stage of mesothelioma, in which tumors that first developed in the lining of the lungs, abdomen, or other areas have spread to other parts of the body. Stage 4 mesothelioma life expectancy is 8-12 months. While life-extending surgeries typically are no longer an option at this stage, chemotherapy may still help extend survival and improve a patient’s quality of life.

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Fact-Checked and Medically Edited by: Dr. Assuntina Sacco, Board-Certified Oncologist

What Is Stage 4 Mesothelioma?

Stage 4 mesothelioma generally refers to malignant (cancerous) mesothelioma that has spread from the location where it first appeared to distant parts of the body.

Depending on the type, mesothelioma may first appear in the:

Pleura: The lining of the lungs and chest wall
Peritoneum: The lining of the abdominal cavity
Pericardium: The lining of the heart
Tunica vaginalis: The membrane lining the testes

Stage 4 mesothelioma is the final stage of mesothelioma under the tumor-node-metastasis (TNM) staging system. In the United States and many other countries, the TNM system is the most widely used system for measuring how far most cancers have progressed.

Doctors use the TNM system to help malignant pleural mesothelioma patients understand the extent of their cancer, how long they can expect to live, and what treatment options may help.

Stage 4 Pleural Mesothelioma

The only officially staged type of mesothelioma is pleural mesothelioma. Stage 4 pleural mesothelioma is described as cancer that has used lymph nodes or blood vessels to travel to distant parts of the body, forming new tumors.

At this advanced stage, life-extending treatments may be extremely limited or unavailable.

Stage 4 Peritoneal Mesothelioma

Peritoneal mesothelioma has no official staging system. However, some oncologists (cancer doctors) have proposed a staging system for peritoneal mesothelioma that has yet to be approved by the TNM staging system’s creators, the American Joint Committee on Cancer (AJCC) and the International Union Against Cancer (UICC).

Under this unofficial staging system, stage 4 peritoneal mesothelioma involves extensive tumor spreading.

Stage 4 Pericardial Mesothelioma

Pericardial mesothelioma is a rare form of the cancer, affecting the lining of the heart. Because it is so uncommon, doctors have not been able to properly stage it. Pericardial mesothelioma is typically described as late-stage or advanced rather than as “stage 4.”

Stage 4 Testicular Mesothelioma

Like pericardial mesothelioma, testicular mesothelioma is very rare. It may be described as late-stage or advanced.

Quick Facts About Stage 4 Mesothelioma

According to the American Cancer Society (ACS), only 8% of mesothelioma patients with distant or stage 4 mesothelioma survive 5 years after diagnosis.
Unlike many other forms of cancer, stage 4 mesothelioma tends to remain in the body cavity it originated in. For example, pleural mesothelioma often remains in the chest.
During stage 4, mesothelioma has usually spread too far for patients to undergo life-extending surgery. However, chemotherapy and treatment through clinical trials may help.

How Late-Stage Mesothelioma Develops

According to the Centers for Disease Control and Prevention (CDC), mesothelioma may take around 20-50 years to develop after a patient has been exposed to asbestos — the only known cause of the cancer. However, once symptoms appear, the disease progresses rapidly.

As mesothelioma cancer cells multiply, they cause tumors to grow and spread. Eventually, these cancer cells may travel through the lymph nodes or blood vessels, forming new tumors far from where they originated — a process called metastasis.

Stage 4 mesothelioma marks the point when the cancer has metastasized (spread to distant parts of the body).

The TNM system describes stage 4 mesothelioma in the following manner:

TNM System Stage 4 Mesothelioma
Tumor	Node	Metastasis
Cancer may or may not have grown into nearby tissues and other body parts.	The cancer may or may not have spread to lymph nodes — either nearby or on the other side of the body.	Cancer has spread to distant organs, such as the bones, the liver, lungs, etc.

As mesothelioma progresses from stage 3 to stage 4, large and spreading tumors cause patients to experience the most severe mesothelioma symptoms.

Stage 4 Mesothelioma Symptoms

During stage 4, the symptoms commonly experienced by mesothelioma patients worsen. As the cancer spreads to other parts of the body, new symptoms may arise or extend to other areas.

Common symptoms of stage 4 mesothelioma include:

Abdominal pain
Anemia
Chest pain
Chronic fatigue
Coughing up blood
Difficulty swallowing
Extreme weight loss
Fever
Muscle atrophy
Night sweats
Shortness of breath

Even at this late stage, the symptoms of mesothelioma are not unique to the disease, but symptoms are more than noticeable enough for patients to bring to their doctors who can run tests in an attempt to identify the problem.

How to Identify Stage 4 Mesothelioma

Since mesothelioma is so rare, many doctors may not immediately consider the possibility that a patient has it unless they are aware of the patient’s exposure to asbestos.

Doctors may perform an X-ray of the area where the symptoms seem to originate (usually the chest) to help them locate abnormalities such as tumors, fluid buildup, and thickening of the organ linings.

Such symptoms are strong signs of mesothelioma but may also indicate lung cancer and other cancers. Awareness of a patient’s asbestos exposure history and further testing are the best ways for a doctor to identify stage 4 mesothelioma.

Stage 4 Mesothelioma Diagnosis

Sadly, many mesothelioma patients are diagnosed during stage 4 because this is when symptoms are most prominent. Misdiagnosis may also contribute to an advanced-stage mesothelioma diagnosis.

Doctors may use the following to help diagnose stage 4 mesothelioma:

Knowledge of a patient’s asbestos exposure history
Patient’s description of symptoms
Physical exam
X-rays and other imaging tests
Blood tests
Biopsy

A biopsy involves the removal of a tissue sample from a patient’s tumor, thickened organ lining, or fluid around the cancer site. By examining this tissue under a microscope, a doctor can determine if any of its cells are cancerous.

Ultimately, a mesothelioma diagnosis can only be confirmed by performing a biopsy.

Stage 4 Diagnosis and Mesothelioma Staging Systems

Once mesothelioma has been diagnosed, doctors use a staging system to find out how far the patient’s cancer has advanced and how they can expect it to progress.

While other systems exist (for pleural mesothelioma only), the TNM staging system is the most widely accepted. Each system focuses on different aspects of mesothelioma, describing stage 4 in its own way.

Stage 4 Pleural Mesothelioma By Staging System
Butchart System	The cancer has metastasized, spreading to distant parts of the body.
Brigham System	There are distant metastases. Tumors are not surgically removable.
TNM System	Mesothelioma may or may not have grown into nearby tissues and may or may not have spread to nearby lymph nodes. However, it has spread to distant organs.

Around the world, many medical communities use the TNM staging system for its simplicity and practicality in terms of understanding a patient’s prognosis.

Stage 4 Mesothelioma Prognosis

A prognosis describes how a disease is expected to progress. The stage of a patient’s mesothelioma at diagnosis is a major factor in determining their mesothelioma prognosis.

Mesothelioma has a poor prognosis in general, and patients diagnosed at stage 4 have the poorest outlook. However, some stage 4 patients may extend their lives with chemotherapy and other treatments.

Palliative treatment may also relieve symptoms, making life with mesothelioma easier.

Stage 4 Mesothelioma Life Expectancy

The average amount of time doctors expect a mesothelioma patient to live after diagnosis is known as mesothelioma life expectancy. For this aggressive cancer, life expectancy is often measured in months.

According to a mesothelioma review published in the West Virginia Medical Journal, the median survival time for malignant mesothelioma of all types is 6-13 months overall and 6-18 months with treatment.

Stage 4 patients, who are often not able to undergo the most effective life-extending treatments, can generally expect to live at the shorter end of this range. However, chemotherapy may increase life expectancy.

Life Expectancy Without Treatment

Mesothelioma patients who choose not to receive life-extending treatment or who cannot undergo such treatment have a median life expectancy of 4-9 months after diagnosis.

For stage 4 mesothelioma cancer patients, this number may be even lower.

However, each individual’s case is unique. Some stage 4 patients may live far longer than expected due to a combination of factors such as overall health, cancer cell type, how their cancer progresses, and more.

Stage 4 Mesothelioma Survival Rate

The percentage of mesothelioma patients who survive for a certain amount of time (often measured in 1-, 3-, and 5-year increments after diagnosis) is known as the mesothelioma survival rate.

Stage 4 mesothelioma patients have the lowest survival rates. The ACS found that only 8% of pleural mesothelioma patients lived for 5 years after being diagnosed at a distant stage (similar to stage 4 under the TNM staging system).

A 2017 study published in Lung Cancer International collected data from over 11,000 pleural and peritoneal mesothelioma patients between 1973–2011 to show how a person’s stage at diagnosis affects survival rates.

The study used language from the older LRD staging system to describe pleural and peritoneal mesothelioma stages:

Localized: Stage 1 mesothelioma contained in one area
Regional: Stages 2, 3, and 4 mesothelioma that has not spread to distant body parts
Distant: Stage 4 mesothelioma that has spread to parts of the body far from where it originated

The tables below show the percentage of mesothelioma patients out of the entire study who lived for at least 1 year or 5 years, respectively, after diagnosis.

Survival Rates for Pleural Mesothelioma by Stage
Mesothelioma Stage	1-Year Survival Rate	5-Year Survival Rate
Localized	41%	6%
Regional	40%	4%
Distant	32%	3%

Survival Rates for Peritoneal Mesothelioma by Stage
Mesothelioma Stage	1-Year Survival Rate	5-Year Survival Rate
Localized	74%	26%
Regional	55%	19%
Distant	40%	11%

A patient’s remaining life expectancy may be greatly influenced by the stage of their mesothelioma after diagnosis. Stage 4 mesothelioma tumors are not resectable (surgically removable), preventing patients from undergoing the most effective treatment options for increasing their life expectancy.

However, stage 4 patients may still benefit from chemotherapy and other treatments.

Stage 4 Mesothelioma Treatment

Stage 4 malignant mesothelioma treatment may involve surgery, chemotherapy, radiation, and/or new treatments through clinical trials.

However, chemotherapy, alone, is the standard recommended treatment for patients with stage 4 mesothelioma.

Stage 4 Mesothelioma Surgery

Stage 4 mesothelioma is usually not able to be operated on because cancer cells have spread to distant parts of the body, growing new tumors. At this stage, the cancer is too widespread for surgeons to effectively remove enough of it, and patients may be too sick to undergo invasive surgeries such as an extrapleural pneumonectomy (EPP) or pleurectomy with decortication (P/D).

However, surgery may still help relieve symptoms and treat complications caused by tumor growth through partial tumor removal.

Stage 4 Mesothelioma Chemotherapy

Chemotherapy, cancer-destroying medicines that are administered intravenously, is the standard treatment option for stage 4 mesothelioma patients.

While some individuals respond well to mesothelioma chemotherapy, a mesothelioma literature review published in the Ochsner Journal found that nearly two-thirds of mesothelioma chemotherapy patients do not respond to the preferred cisplatin and pemetrexed chemotherapy drug combination.

However, a new type of chemotherapy known as targeted therapy shows some promise as a more effective mesothelioma treatment option. Several targeted therapies are currently being studied in clinical trials.

Stage 4 Mesothelioma Radiation Therapy

During mesothelioma radiation therapy, doctors use high-energy rays to destroy the DNA of mesothelioma cancer cells.

For stage 4 mesothelioma patients, radiation therapy is most commonly used to help shrink tumors that can be directly targeted, relieving pain.

Many advanced-stage mesothelioma patients do not respond effectively to typical cancer treatments like surgery, chemotherapy, and radiation. However, other options are available.

Other Treatment Options

Stage 4 mesothelioma patients are often not ideal candidates for the most commonly applied treatments. However, some late-stage patients may find better results by participating in a clinical trial.

Mesothelioma clinical trials test emerging treatments for the disease to improve the treatment options that are currently available.

Emerging mesothelioma treatments include:

Anti-angiogenesis
Gene therapy
Immunotherapy
Photodynamic therapy

Patients should keep the stage of their mesothelioma in mind when searching for clinical trials. Many trials restrict patients by cancer stage.

Stage 4 Mesothelioma Palliative Care

Palliative care describes treatment aimed not at extending life but at decreasing pain and increasing comfort and wellbeing. Many stage 4 mesothelioma patients do not receive much benefit from chemotherapy and cannot undergo surgery to extend their lives.

Therefore, doctors focus on reducing their symptoms and giving them the best quality of life possible during the final stage of their cancer.

Palliative care options for stage 4 mesothelioma include:

Chemotherapy: Chemotherapy helps reduce the size of tumors, easing symptoms.
Medication: Doctors may prescribe medication such as morphine to help patients manage their pain.
Radiation: Like chemotherapy, radiation may shrink cancerous tumors and ease symptoms.
Low-risk surgeries: Palliative surgery for mesothelioma may reduce fluid buildup or partially remove tumors.

For those who have reached the final stage of their mesothelioma, palliative care is central to optimal treatment.

End-of-Life Planning And Living With Stage 4 Mesothelioma

Stage 4 mesothelioma is the final stage of this aggressive cancer, and many patients live fewer than 6 months after diagnosis.

While such a diagnosis can be devastating, patients may ease anxiety and improve their general wellbeing by managing their treatment and making an end-of-life plan.

This plan may include:

Care Setting

Patients should speak with their loved ones about where they wish to receive end-of-life care (hospital, hospice, at home, etc.) and whether they would like to designate someone as their caregiver.
Care of Dependents

Patients with dependent children or grandchildren, pets, or anyone else reliant on their care should make arrangements to make sure those who survive them are taken care of.
Funeral Arrangements

Patients should let loved ones know how they want their body to be handled (cremation, burial, etc.), details about the funeral service, and any special religious requests.
Personal Records

A trusted loved one should have access to any important information they may need to know, such as the patient’s social security number and passwords.
Treatment Management

A patient’s treatment team should know their priorities when it comes to treatment. Do they want to focus on extending survival time or easing symptoms? At some point, patients may wish to end all standard cancer treatments like chemotherapy and surgery.
Will and Other Finances

Patients should review or draft a will and make sure to account for all income and assets, such as investments, personal possessions, and other forms of compensation. An advance directive also gives you the opportunity to spell out your decisions regarding end of life care in advance. This includes whether or not you wish to receive life-sustaining therapies such as CPR, being on a breathing machine (ventilator), artificial nutrition or hydration. While these decisions may be difficult to discuss with your doctor or family, doing so ahead of time ensures that your wishes are followed, minimizing any unwanted procedures or unnecessary suffering.

Patients can ask their medical team for recommended end-of-life care documents and where they may receive further end-of-life planning assistance.

By working with their care team and planning ahead, stage 4 mesothelioma patients may experience a greater sense of peace and satisfaction at the end of their lives.

Reviewed by:Dr. Assuntina Sacco

Board-Certified Oncologist

Fact-Checked
Editor

Assuntina Sacco, MD is an Associate Professor of Internal Medicine at the University of California, San Diego (UCSD) Moores Cancer Center, where she also serves as the Medical Director of Infusion Services. She is a board-certified medical oncologist trained to treat all solid tumor types, with the use of chemotherapy, immunotherapy, targeted therapy, and clinical trials.

Dr. Assuntina Sacco is an independently paid medical reviewer.

Written by:Stephanie Kidd

Editor-in-Chief

Stephanie Kidd grew up in a family of civil servants, blue-collar workers, and medical caregivers. Upon graduating Summa Cum Laude from Stetson University, she began her career specializing in worker safety regulations and communications. Now, a proud member of the American Medical Writers Association (AMWA) and Editor-in-Chief of the Mesothelioma Cancer Network, Stephanie serves as a voice for mesothelioma victims and their families.

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