Stage 4 Mesothelioma

What Is Stage 4 Mesothelioma?

Stage 4 malignant mesothelioma refers to cancer that has metastasized, or spread to distant areas in the body. It may be expressed with Roman numerals — stage IV — or with numerals such as mesothelioma at stage 4.

In stage 4 disease, cancer cells may have reached lymph nodes and several organs, including the brain, prostate, spine and the lining of the heart.

This is the most advanced and difficult stage to treat because available therapy options cannot remove all tumors. Some patients with stage 4 disease are too weak for aggressive surgeries and other therapies, too.

Is Mesothelioma Terminal?

Mesothelioma is considered terminal at stage 4. Your mesothelioma life expectancy with stage 4 cancer depends largely on the extent of tumor growth and how well you respond to treatments. 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 beyond their initial mesothelioma prognosis.

Symptoms of Stage 4 Mesothelioma

At stage 4, also known as end-stage or late-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 the chest or abdomen
• Abdominal pain
• Fatigue
• Severe weight loss or anorexia (lack of appetite)
• General feeling of discomfort (malaise)

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

Unfortunately, a number of stage 4 mesothelioma cases do not produce symptoms that clearly indicate a diagnosis of mesothelioma. The symptoms of mesothelioma lead most general practitioners to a diagnosis of pneumonia or another pulmonary condition. In most cases, mesothelioma is diagnosed in stage 4 at a hospital or cancer center by an oncologist and not by general practitioner.

Late-Stage Mesothelioma by Type

Each type of mesothelioma has unique characteristics at the late stages of the cancer.

Stage 4 Pleural Mesothelioma

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

Pleural disease can take the form of epithelial or sarcomatoid cell tumors. Cell type does not affect how stage 4 disease is diagnosed, but it does affect how it can be treated at this stage.

Stage 4 Peritoneal Mesothelioma

There is no official stage 4 for peritoneal mesothelioma. This type of the cancer accounts for roughly 20% of all mesothelioma 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 moved outside of the peritoneum. Surgery usually is not an option for stage 4 peritoneal mesothelioma.

For people who can try surgery, heated intraperitoneal chemotherapy (HIPEC) is the most promising option. It combines surgery and heated chemotherapy circulated throughout the abdomen.

Stage 4 Pericardial Mesothelioma

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 Testicular Mesothelioma

Testicular mesothelioma is the rarest type of this cancer, with around 100 cases documented in medical literature. As with the pericardial type, testicular mesothelioma may not be defined as stage 4, but it is recognized as advanced disease in most cases.

Quick Fact:

Three systems are commonly used to define stages of pleural mesothelioma (Brigham, TNM and Butchart). They categorize stage 4 on similar cancer characteristics and tumor behaviors. Butchart and TNM note whether the cancer has metastasized to distant organs. Brigham designates when surgery is not a viable option.

Treatment for Mesothelioma at Stage 4

Treatment options to extend survival are most limited at stage 4. Aggressive surgeries to remove tumors typically are not an option because the tumor has spread too far.

For many patients with advanced disease, chemotherapy is the best option. Even though it won’t cure the disease, this treatment can shrink tumors to improve quality and length of life.

Targeted radiation therapy also can be used in a palliative treatment plan. Radiation treatments may alleviate pain and pressure and ease breathing.

Stage 4 Chemotherapy

Chemotherapy is one of the most common treatment options for stage 4 mesothelioma. These drugs slow tumor growth and may shrink tumors in some cases. This helps alleviate symptoms and extend survival.

A 2016 Wayne State University study out found chemotherapy more than doubles life expectancy for malignant mesothelioma patients, including those with stage 4 disease. 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).

Stage 4 Surgery

Extensive tumor-removing surgeries, such as a pleurectomy/decortication (P/D) or extrapleural pneumonectomy (EPP) are not routinely offered to patients with stage 4 disease.

Due to the extensive spread of tumors at stage 4 disease, doctors cannot remove all growths with EPP or P/D.

Still, some patients can benefit from less extensive surgical procedures. Surgeons will attempt to remove as much tumor mass as possible in a procedure called debulking.

They can target tumors causing symptoms, so patients breathe more comfortably and experience less pain.

Less invasive surgeries that 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

Stage 4 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 is used to reduce the size of tumors. This can lessen chest pressure, decrease pain and improve breathing.

Learn More About Mesothelioma Treatment Options

Immunotherapy and Clinical Trials

Some stage 4 mesothelioma patients may qualify for clinical trials. Clinical trials investigate the value of various treatment combinations for late-stage mesothelioma or may test newer options such as immunotherapy.

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 pleura mesothelioma patients with no cancer cells in their lymph nodes lived an average of 7.3 years compared with the typical one-year prognosis.

Supportive Care

Supportive or palliative care can 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 into their treatment plan. Certain complementary therapies may improve survival, ease symptoms, reduce treatment side effects and enhance quality of life.

Examples include mind-body therapies, nutritional support, acupuncture, massage and herbal treatments.

Life Expectancy Without Treatment

How long someone lives with mesothelioma without treatment depends the cancer’s stage, their overall health and tumor growth rates.

Patients diagnosed with stage 1A disease who elect no treatment live an average of two years. Those diagnosed in stage 4 who decide against treatment live an average of 6 months.

Researchers use tumor grading to estimate how fast a tumor may grow. Cell abnormalities and how rapidly the cancer cells are dividing play a role in overall tumor growth. These factors are associated with survival.

Tumor Grades and 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 and Prognosis

At stage 4, the cancer is likely to continue to spread, which can lead to respiratory failure. If the tumors spread to the heart the patient may experience heart failure. 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 variable cancer and 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 combining immunotherapy 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 to manage symptoms 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 predicted 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:

Steps to Consider After a Stage 4 Diagnosis

• Get a second opinion from a mesothelioma specialist.
• Find financial assistance available to offset potential monetary 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.

End-of-Life Planning

Palliative care to manage pain plus ongoing communication with your medical team can vastly improve your quality of life with mesothelioma.

In addition to these options, you’ll want to make a plan for your end-of-life choices and tell your family why these decisions are important to you. Knowing your family will honor your end-of-life care plan will lessen anxiety.

Documenting your decisions in clear, concise, legally binding documents can help you feel better, too. Ask your medical team for a blank copy of all documents they recommend when planning for end-of-life medical care.

Considerations for End-of-Life Decision Making

• Symptoms versus cancer & control: Treatments can focus on killing tumors or solely on managing symptoms. Tell your medical team which goal is more important to you.
• Care location: Tell your doctors and nurses where you want to receive care if you are unable to go to an outpatient clinic. Some people want to be in the hospital or a 24-hour, staffed hospice program. Others want to designate a caregiver and arrange for in-home medical services.
• Financial affairs: Make sure all the beneficiaries for insurance policies, employer or union benefits , lawsuits, tax returns, checking and savings accounts, personal possessions and investments (IRA or 401k) are clearly specified in your will.
• Personal records: Provide your social security number, passwords and important contacts to a trusted family member.
• Other family care needs: Identify who will take care of children or pets.
• Funeral arrangements: Provide detailed information on how you want your body handled, the type of memorial or funeral service you’d like and how it will be paid for.

A stage 4 mesothelioma diagnosis can be devastating, but it doesn’t mean you can’t control some aspects of your cancer.

Taking a proactive approach, combined with a variety of treatments, may help people live longer.

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