Stage 4 Cancer – Mesothelioma

Stage 4 is the most advanced of the four mesothelioma stages. Tumors have spread throughout the chest cavity and possibly to distant organs. Tumor-removing surgery is generally not an option, and most treatments aim to ease symptoms and reduce pain. Life expectancy for stage 4 mesothelioma is usually less than a year.

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By stage 4, malignant mesothelioma tumors have metastasized, or spread beyond the point of origin to other parts of the body. The cancer may have spread to lymph nodes and several organs of the body, including the brain, prostate, spine and the lining of the heart.

Stage 4 mesothelioma — commonly expressed with Roman numerals as stage IV — is the most advanced stage and most difficult to treat because the few treatment options available cannot remove all tumors. Many patients are also too weak to withstand aggressive surgeries.

Quick Fact

The three systems commonly used to define stages of pleural mesothelioma (Bringham, TNM and Butchart) categorize stage 4 on similar characteristics and behaviors. Butchart and TNM note that the cancer has metastasized to distant organs, while Brigham designates that surgery is not a viable option.

Although stage 4 mesothelioma is considered terminal, continued advancements in palliative care can help you live longer and have a better quality of life. Some stage 4 patients continue to defy the odds, living years after their initial mesothelioma prognosis.

Your outlook depends largely on the extent of tumor growth and how well you respond to treatments.

Symptoms of Stage 4 Mesothelioma

At stage 4, also known as end-stage mesothelioma, common symptoms such as breathlessness and coughing are more severe. Because tumors have spread beyond the lungs, symptoms are not isolated to the chest cavity.

Common symptoms of late-stage mesothelioma include:

  • Shortness of breath (dyspnea)
  • Pain and tightness in the chest
  • Night sweats and fever
  • Difficulty swallowing (dysphagia)
  • Coughing up blood (hemoptysis)
  • Fluid buildup in chest or abdomen
  • Abdominal pain
  • Fatigue
  • Severe weight loss or anorexia
  • Generally feeling of discomfort (malaise)

Some patients also suffer from cachexia, a syndrome involving weight loss, muscle atrophy, weakness and appetite loss. Stage 4 cancer sometimes causes blood problems, including high platelet count (thrombocytosis) and low red blood cell count (anemia).

Stage 4 Mesothelioma Treatment Options

Although no curative treatment exists for any stage of mesothelioma, treatment options that aim to extend survival are the most limited at stage 4.

Extensive tumor-removing surgeries such as a pleurectomy/decortication (P/D) or extrapleural pneumonectomy (EPP) are typically not an option, but palliative treatments — including chemotherapy and radiation therapy — slow tumor growth and reduce tumor size.


While the spread of tumors is usually too vast at stage 4 for doctors to remove all growths, some patients can benefit from less extensive surgical procedures. Surgeons can attempt to remove as much tumor mass as possible. They can also target only problematic tumors so patients breathe more comfortably and experience less pain.

Less invasive, palliative surgeries that can relieve pain and reduce symptoms include:

  • Thoracentesis: Drains fluid from the chest
  • Paracentesis: Drains fluid from the abdomen
  • Pericardiocentesis: Drains fluid from around the heart
  • Pleurodesis: Potential long-term solution to fluid buildup in the chest


Chemotherapy is one of the most common treatment options for stage 4 mesothelioma. Chemotherapy drugs slow tumor growth and may shrink tumors in some cases, helping to alleviate symptoms and extend survival. Wayne State University researchers in 2016 found chemotherapy more than doubles life expectancy for malignant mesothelioma patients, including those in stage 4. Combining chemotherapy with surgery extended survival even longer.

The most commonly prescribed chemotherapy regimen for pleural mesothelioma is cisplatin or carboplatin combined with pemetrexed (Alimta).

Radiation Therapy

Doctors don’t always treat stage 4 mesothelioma with radiation therapy, but they may recommend the procedure depending on your tumor growth and overall health. Radiation therapy at this stage might be able to reduce the size of tumors, which can lessen chest pressure, decrease pain and improve breathing.

Immunotherapy and Clinical Trials

Certain stage 4 mesothelioma patients may qualify for clinical trials. Some clinical trials investigate the value of various treatment combinations for late-stage mesothelioma. In some cases, experimental treatments such as immunotherapy, gene therapy or other emerging therapies can help stage 4 patients survive far past their prognosis.

A 2016 study published in The Annals of Thoracic Surgery showed a correlation between the use of light energy — or photodynamic therapy — and late-stage mesothelioma survival. A subset of patients with pleura mesothelioma achieved a median overall survival of 7.3 years compared to the usual one-year prognosis.

Supportive Care

Supportive or palliative care helps to relieve symptoms and improve quality of life. At stage 4, doctors may recommend pain medication, oxygen therapy and respiratory therapies to control pain and improve lung function.

Numerous long-term mesothelioma survivors have incorporated complementary and alternative medicine therapies into their treatment plan. Certain complementary therapies are known to improve survival, ease symptoms, reduce treatment side effects and enhance quality of life. These treatments include herbal medicine and holistic therapies, mind-body therapies (yoga, qigong and tai chi) and nutritional therapy.

Find a Top Mesothelioma Doctor

A mesothelioma specialist can help patients diagnosed with stage 4 determine the best treatment plan possible.

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Late Stages by Mesothelioma Type

Stage 4 typically refers to pleural mesothelioma, the most common type of the asbestos-related cancer.

There is no official stage 4 for peritoneal mesothelioma, which accounts for roughly 20 percent of all cases. However, it is generally accepted that peritoneal patients with extensive tumor spreading are classified as stage 4.

By this point, the cancerous tissue is more extensive and tumors have spread outside of the peritoneum — the protective lining of the abdomen where the cancer initially develops.

Like pleural mesothelioma, surgery is usually not an option at this phase. This includes heated intraperitoneal chemotherapy (HIPEC), a promising peritoneal treatment that combines surgery and heated chemotherapy.

Pericardial mesothelioma, a rare form of the cancer which develops on the lining of the heart, is typically diagnosed in the later stages, although it may not be defined as stage 4.

Stage 4 Prognosis & Life Expectancy

At stage 4 the cancer is likely to continue to spread, which can lead to respiratory failure or heart failure if tumors spread to the heart.

The median survival rate for stage 4 mesothelioma is about 12 months. A positive response to treatment can extend survival, and patients with good prognostic factors often live longer than average. Prognostic factors associated with better survival include having the epithelioid cell type, being in good overall health, younger in age, female and having no signs of blood disorders.

“A stage 4 mesothelioma diagnosis doesn’t mean there is no hope or options. It’s important to connect with a medical oncologist that is experienced with mesothelioma to understand your treatment options. Remember, you are the decision maker. Your specialist is there to give you guidance.”

— Karen Selby, RN

Mesothelioma is considered a heterogeneous cancer, meaning no two cases are the same. For this reason, survival statistics cannot predict how long someone with mesothelioma will live. Some people have particularly slow-developing mesothelioma, and some respond surprisingly well to treatment.

What’s Next After a Stage 4 Mesothelioma Diagnosis?

Although stage 4 is the most advanced of the mesothelioma stages, some patients, especially those in good overall health, live far beyond their life expectancy. Through a variety of treatments, groundbreaking clinical trials and healthy life choices, you can beat the odds and become a survivor. Consider the following:

  • Get a second opinion from a mesothelioma specialist.

  • Find financial assistance available to offset potential financial burden.

  • Enroll in a clinical trial. Consult with your doctor to determine if you are eligible.

  • Try alternative and complementary treatment options.

  • Exercise and maintain a healthy diet to improve mood and quality of life.

  • Join a support group to connect with others coping with mesothelioma.

  • Make time for hobbies and activities that bring you joy.

  • Read stories about other mesothelioma survivors for hope and inspiration.

A stage 4 mesothelioma diagnosis can be devastating, but it doesn’t mean it’s a death sentence. A positive outlook will do wonders when combined with a variety of treatments.

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Karen Selby, RN and Patient Advocate at The Mesothelioma Center

Karen Selby joined in 2009. She is a registered nurse with a background in oncology and thoracic surgery and was the director of a tissue bank before becoming a Patient Advocate at The Mesothelioma Center. Karen has assisted surgeons with thoracic surgeries such as lung resections, lung transplants, pneumonectomies, pleurectomies and wedge resections. She is also a member of the Academy of Oncology Nurse & Patient Navigators.

Medical Review Checkmark

Medical Review By

  1. Pass, H., Vogelzang, N. and Carbone, M. Malignant Mesothelioma: Advances in Pathogenesis, Diagnosis, and Transitional Therapies. Springer: 2005.
  2. American Cancer Society. (2015, May 18). How is Malignant Mesothelioma Staged? Retrieved from
  3. Vanderbilt University Medical Center. (2013, January 18). Mesothelioma. Retrieved from
  4. Rice, D. (n.d.). Staging of Malignant Pleural Mesothelioma: A Guideline for Patients. Retrieved from
  5. American Cancer Society. (2015, May 18). Treatment of Mesothelioma Based on the Extent of the Cancer. Retrieved from
  6. American Cancer Society. (2015, May 18). Palliative Procedures for Malignant Mesothelioma. Retrieved from
  7. American Cancer Society. (2015, May 18). How is Malignant Mesothelioma Diagnosed? Retrieved from
  8. American Cancer Society. (2015, May 18). Chemotherapy for Malignant Mesothelioma. Retrieved from
  9. Pinto, C. et al. (2006, May). Sequential Therapy with Cisplatin/Gemcitabine (CG) Followed by Mitoxantrone/Methotrexate/Mitomycin (MMM) in Patients with Malignant Pleural Mesothelioma. A Multicenter Italian Phase II Study (SITMP1). Retrieved from
  10. Van Meerbeeck, J. et al. (2005, May 12). Randomized Phase III Study of Cisplatin With or Without Raltitrexed in Patients with Malignant Pleural Mesothelioma: An Intergroup Study of the European Organisation for Research and Treatment of Cancer Lung Cancer Group and the National Cancer Institute of Canada. Retrieved from
  11. Kalmadi, S. et al. (2007, November 19). Gemcitabine and Cisplatin in Unresectable Malignant Mesothelioma of the Pleura: A Phase II Study of the Southwest Oncology Group (SWOG 9810). Retrieved from
  12. Fennell, D.A. et al. (2005, February). Phase II Trial of Vinorelbine and Oxaliplatin as First-line Therapy in Malignant Pleural Mesothelioma. Retrieved from
  13. The American College of Chest Physicians. (1995). A Proposed New International Staging System for Malignant Pleural Mesothelioma. Retrieved from
  14. Moore, A., Parker, R. and Wiggins, J. (2008, December 19). Malignant Mesothelioma. Retrieved from
  15. Beebe-Dimmer, J. et. al. (2016, October 26). Mesothelioma in the United States: A Surveillance, Epidemiology, and End Results (SEER)–Medicare Investigation of Treatment Patterns and Overall Survival. Retrieved from
  16. Friedberg, J. et al. (2016, November 5). Extended Pleurectomy-Decortication–Based Treatment for Advanced Stage Epithelial Mesothelioma Yielding a Median Survival of Nearly Three Years. Retrieved from

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