Stage 4 Mesothelioma

Stage 4 mesothelioma is the most advanced form of the disease, often accompanied by severe symptoms and an extremely poor prognosis.

Key Points

  • 1

    Stage 4 mesothelioma indicates the disease has spread significantly through the body.

  • 2

    By stage 4, mesothelioma symptoms are the most severe and often systemic.

  • 3

    At this stage, patients generally only have palliative treatment options.

  • 4

    Stage 4 mesothelioma has the worst prognosis, on average only about 12 months.

Because mesothelioma is so difficult to detect early, many patients are not properly diagnosed until it has progressed to a later stage. Stage 4 mesothelioma is the most advanced form of the disease, and indicates that the cancer has spread beyond its initial location. At this point, the cancer usually has spread throughout the chest cavity, into the abdomen and lymph nodes, and in some cases may even travel to the brain.

Because of the severity of the disease, the average life expectancy is about 12 months. Due to the spreading, curative surgery and other curative treatments may no longer be an option. Most patients will only be able to receive palliative treatment to help relieve their symptoms, rather than trying to cure the disease itself.

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Stage 4 Mesothelioma By Type

For every form of mesothelioma, as the stage advances patients generally have more limited treatment options and a worse prognosis. For pleural and peritoneal mesothelioma patients, more studies are emerging focused on finding better treatment options to slow the advance of the disease and improve quality of life.

Stage 4 Pleural Mesothelioma

As the most common form, pleural mesothelioma is the only type to have defined staging systems when diagnosing the disease. Currently, doctors may rely on three different systems when categorizing the stage of a patient’s cancer. Though each system has slightly different criteria and descriptions for each stage, all three systems generally define stage 4 pleural mesothelioma in the same manner.

Mesothelioma Stages - TNM System

Refers to disease which is confined to the primary site, or site of origin. The lymph nodes are free of disease and there are no metastases present. Most often, treatment for stage I mesothelioma consists of surgical resection, or removal, of the disease.

Refers to disease which is confined to one site. While the lymph nodes are still free of disease and there are no metastases present, the tumor extends into the deeper pleural surfaces on the same side as the tumor as well as at least one of the following: the diaphragm or the lung.

Refers to disease which either has spread to lymph nodes on the same side as the tumor; or, a tumor which is extensive and involves the deeper pleural surfaces as well as at least one of the following: chest wall, thoracic fascia, sac around the heart, or mediastinal fat. The tumor is still considered resectable by surgery. There is no metastasis present.

Refers to disease in which one of the following occurs: the tumor is too extensive for surgery, there is distant lymph node involvement on the opposite side from the tumor, or there is distant metastasis present.

The other two systems, Butchart and Brigham systems, describe stage 4 pleural mesothelioma in much the same way. According to the Brigham system, this stage of disease demonstrates distant spreading of the cancer throughout the body. The Butchart system specifies stage 4 indicates there is evidence  the pleural mesothelioma has spread in the bloodstream to other organs.

Stage 4 Peritoneal Mesothelioma

Though peritoneal mesothelioma has no formal staging system like pleural mesothelioma, there are some methods oncologists have developed to better describe the severity of the disease.

Some doctors may rely on the Peritoneal Cancer Index, or PCI, which creates a scoring system through the abdomen based on the number and size of tumors found in a particular region. The body is separated into 13 sections, and each region will be given a number between 0 and 3. The score of each region added together is a patient’s PCI score.

A score of 31-39 has been used by some researchers as a translation for a typical stage 4 of the disease as described in the staging systems for pleural mesothelioma. Stage 4 peritoneal mesothelioma will likely indicate larger, more numerous tumors that have likely spread throughout the abdominal cavity and chest wall, and even into the lymph nodes.

Stage 4 Pericardial Mesothelioma

Unfortunately, there is limited information available around pericardial mesothelioma overall because it is extremely rare. As such, this form of mesothelioma has no proper staging system. Because of its extreme difficulty to diagnose properly, it often isn’t discovered in patients until it has developed to a later stage. In some cases, the disease isn’t even discovered until posthumously in an autopsy report.

Based on information from the staging systems available, stage 4 pericardial mesothelioma would typically be described as the spreading of tumors beyond the pericardium and throughout the chest. This spreading may also be found in the abdomen or esophagus.

Symptoms of Stage 4 Mesothelioma

By this stage, patients will likely experience more noticeable and severe symptoms. These will vary depending on a patient’s type of mesothelioma, as well as where in the body the mesothelioma has spread. In many cases, a treatment plan developed for stage 4 patients will largely focus on helping to relieve some of these worsening symptoms.

Stage 4 Mesothelioma Symptoms

  • Fever and night sweats
  • Chest tightness and pain
  • Shortness of breath and difficulty breathing
  • Abdominal pain
  • Fluid accumulation in chest or abdomen
  • Weight loss
  • Difficulty swallowing (dysphagia)
  • Coughing up blood (hemoptysis)

Stage 4 Mesothelioma Life Expectancy

Patients diagnosed with stage 4 mesothelioma typically face a life expectancy of only about one year. A number of factors can influence their survival, like the type of mesothelioma they have, the cell types in the tumors, and a patient’s age and overall health before being diagnosed.

In some cases, stage 4 mesothelioma patients have been able to extend their life expectancy through treatment, though it’s important to keep in mind how difficult the cancer is to treat at this point. For the majority of patients, improving quality of life is the main focus. Having a good support system with your loved ones and finding a support group can make coping with this poor prognosis a bit easier.

Treating Stage 4 Mesothelioma

For most patients with advanced stage mesothelioma, palliative treatment is the main focus. Palliative care may still consist of one or a combination of standard treatments like surgery, chemotherapy and radiation, but with different intents. Instead of trying to remove or cure the cancer, palliative treatment focuses on alleviating symptoms.

Surgery

Though at this stage, the tumors are usually too widespread for a complete resection of the disease, surgery may still be an option to remove one or several tumors to improve symptoms. Depending on the type of mesothelioma, patients may also have surgery to remove excess fluid. Pleural mesothelioma patients, for instance, commonly undergo either a pleurodesis or thoracentesis to help improve breathing and relieve the pressure from this added fluid in the lungs.

Chemotherapy

Similarly to its curative use, chemotherapy can be applied palliatively to shrink the size of the tumors. Since chemotherapy can be used for widespread region, rather than a localized point like with surgery or radiation, it can be a beneficial treatment for alleviating symptoms caused by the metastasis at this stage. Some more recent studies have also found that some combinations of chemotherapy may be able to help late-stage mesothelioma patients survive longer than expected. One study found a combination of pemetrexed and cisplatin (a standard of care for pleural mesothelioma) with another drug, bevacizumab, could extend late-stage pleural mesothelioma patients survival to nearly 19 months on average.

Radiation

In more advanced stages of mesothelioma, radiation therapy isn’t often prescribed even palliatively. This is because at this point the cancer has often spread throughout the abdominal region, and radiation is considered a localized treatment. But in some cases, this therapy may be applied to help reduce tumor sizes and relieve some pressure in the abdominal region. Radiation has shown to be beneficial for some patients in reducing pain and improving breathing.

Clinical Trials and Emerging Treatments

Even though the prognosis at the late stages of this disease are even more grim, there is always hope. Though many patients focus on palliative care, there are many studies around new curative options for late-stage mesothelioma. Researchers are conducting clinical trials around new types of treatments, as well as new treatment combinations to potentially extend life expectancy for these patients.

One of these curative studies focused on combining surgery with photodynamic therapy, a new kind of treatment that uses light with reactive agents to target and kill cancerous cells. Participants in the study were all diagnosed with stage 3 or stage 4 pleural mesothelioma and underwent surgery before the photodynamic therapy was applied. For 73 of these patients, a median overall survival of 3 years was achieved. For 19 patients whose advanced mesothelioma had not yet spread to their lymph nodes, the median survival was 7 years.

These astonishing results gives both patients and researchers hope that even mesothelioma in advanced stages can be potentially treated. Hopefully with continued research into standard and emerging treatments, researchers will find more opportunities and success in treating late stage mesothelioma.

End of Life Planning

Despite some of the successes seen in these clinical trials, an unfortunate reality of mesothelioma is researchers have yet to find a cure and these later stages are extremely difficult to treat. When facing a terminal illness, as difficult as it can be, patients and their loved ones need to plan for what’s to come.

Medical Decisions

For patients at such an advanced stage, it may be more comfortable to seek palliative care outside of the hospital walls. It’s important to consider if hospice or at-home care will make this trying time a little more manageable and less stressful. Hospice focuses on palliative care and keeping patients comfortable as they face the end stages of disease, and can be administered through a particular hospice facility or at a patient’s home.

When seeking in-home care specifically, hospitals where treatment has occurred will be able to suggest facilities or organizations with the best professional caregivers. Whatever you may choose, the most important is ensuring the patient feels comfortable, supported, and can be with their loved ones.

Patients may also consider enacting a DNR, or “Do Not Resuscitate” order. A DNR is a legal agreement the patient will need to have signed by their doctor and in their hospital file, which  ensures the medical team cannot resuscitate the patient in the event of respiratory or cardiac arrest. Though it’s difficult to think about the possibility of no longer fighting for survival, a DNR has given many patients peace of mind knowing they will have a natural passing.

Legal Decisions

One of the most essential tasks patients and their loved ones should consider when facing advanced mesothelioma is creating a will. By having a Last Will and Testament in place, a patient can ensure that any of their belongings, property, business assets, and their financial accounts are distributed to those of their own choosing. Without a will in place, surviving family members will otherwise have to go through a process, known as probate, to settle the estate.

Patients may also find it necessary to appoint someone to help in future decision making as the mesothelioma continues to advance. By appointing a health care power of attorney, this person can make medical decisions on the patient’s behalf that should align with the patient’s wishes. This could include decisions like where treatment occurs, what medications are ok to take, and whether or not a patient would want to be put on life support. Choosing a power of attorney who understands the patient’s ethics and desires is essential to ensure the patient receives the care they want.

When going through these difficult decisions and planning for the future, it’s important to know you have support and don’t have to face this journey alone. Finding a support group, as well as leaning on friends and families, can make this trying time a little easier.

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Medically Reviewed By A/Prof. Tom John A/Prof. Tom John

Dr. Tom John is a medical oncologist, associate professor, and senior clinical research fellow at the Olivia Newton-John Cancer Research Institute in Melbourne, Australia.