Stage 4 Mesothelioma

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 is commonly expressed with Roman numerals as stage IV. It 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.

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
• General feeling of discomfort (malaise)

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

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. 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 peritoneum is 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). HIPEC is a promising peritoneal treatment that combines surgery and heated chemotherapy.

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

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. Palliative treatments, including chemotherapy and radiation therapy, can slow tumor growth and reduce tumor size.

Surgery

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

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. This helps 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. 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. This 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 can help stage 4 patients survive far past their prognosis. These include immunotherapy, gene therapy and other emerging therapies.

A 2016 study published in The Annals of Thoracic Surgery showed photodynamic therapy may improve late-stage mesothelioma survival. A subset of patients with pleura mesothelioma who had no cancer in their lymph nodes lived an average 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. These treatments control pain and improve lung function.

Many long-term mesothelioma survivors have incorporated complementary and alternative medicine therapies into their treatment plan. Certain complementary therapies may 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.

Life Expectancy Without Treatment

How long someone may live with mesothelioma without treatment depends on a few factors. These factors include the cancer’s stage and how fast tumors grow.

Patients diagnosed in stage 1A who refuse treatment live an average of two years. Those diagnosed in stage 4 who decide against treatment live an average of 6 months.

Researchers have developed a way to estimate how fast tumors may grow called tumor grading. It looks inside cancer cells for abnormalities and counts how many times the cancer cells are dividing. These factors are associated with survival.

There are three tumor grades. Higher tumor grades are linked to shorter survival.

• Grade 1 average survival is 28 months
• Grade 2 average survival is 14 months
• Grade 3 average survival is 5 months

Stage 4 Mesothelioma Life Expectancy & Prognosis

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 with treatment.

A positive response to treatment can extend survival. 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.

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.

Stage 4 Mesothelioma Survivors

A number of stage 4 mesothelioma patients have far outlived the average prognosis.

Andy Ashcraft lived with stage 4 pleural mesothelioma for seven years. He joined a clinical trial that combined an immunotherapy drug with chemotherapy. Andy responded better than anyone else in the trial. He continued to take just the immunotherapy drug for more than three years. When it stopped working, he used medicinal cannabis and lived several more years.

Lannie Chitwood lived for 10 years with stage 4 pleural mesothelioma. He received treatment at Duke University Medical Center in Durham, North Carolina, including experimental chemotherapy. Lannie and his wife enjoyed traveling together during those years and took a second honeymoon in 2015.

Comedian Quincy Jones was diagnosed with stage 4 peritoneal mesothelioma in 2015 at the age of 31. Doctors told him that he might have only one year to live. He has lived more than three years thanks to chemotherapy and his love for laughter.

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 may 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 an immediate death sentence. A positive outlook combined with a variety of treatments may help people live longer.

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Karen Selby, RN

Registered Nurse and Patient Advocate

Karen Selby joined Asbestos.com 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.

Edited by Walter Pacheco

Medical Review By Dr. Jay Zatzkin