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Stage 4 Mesothelioma

Stage 4 mesothelioma is the most advanced stage—and is considered terminal with an average life expectancy of less than one year. At this stage, cells have metastasized and spread to distant organs, tissues, and lymph nodes. Treatment includes palliative care to improve quality of life. 

Stage 4 mesothelioma characteristics

Stage 4 mesothelioma has spread or metastasized to organs and structures of the body far from where the tumor first appeared. If you’ve been diagnosed with stage four mesothelioma, the disease may have spread too far for curative treatment. You can, however, have palliative treatment and participate in clinical trials where researchers test new treatments that may improve your prognosis.

Learn more about clinical trials that may offer unique treatments for stage 4 mesothelioma patients.

Stage 4 mesothelioma quick facts

  • At stage 4, cancer has spread throughout the chest wall, pericardium, and diaphragm.
  • Mesothelioma cells have invaded lymph nodes located far from where the tumor first appeared.
  • Because mesothelioma has spread so far, doctors primarily use treatment to improve a patient’s quality of life.
  • Life expectancy is about 12 months.


Types of stage 4 mesothelioma

There are four main types of mesothelioma, named for where cancer originates in the body:

  • Pleural, found in the lining of the lungs (pleura)
  • Peritoneal, originating in the tissue lining the abdominal wall (peritoneum)
  • Pericardial, starting in the membrane surrounding the heart
  • Testicular, found in the testes

However, by stage 4, cancer has metastasized to distant parts of the body beyond where it originated. Cancer staging, type, and metastasis will influence the course of treatment, including palliative care.

Stage 4 pleural mesothelioma

Malignant pleural mesothelioma is the most common type of mesothelioma, accounting for an estimated 80 percent of new cases. This mesothelioma is staged with the TNM staging system – the main system used to stage mesothelioma. 

During stage 4, tumors have spread beyond the pleura to distant parts of the body. In this advanced stage, pleural mesothelioma patients may experience shortness of breath, chest pain, fatigue, unexplained weight loss, persistent cough, and night sweats.

Stage 4 peritoneal mesothelioma

Peritoneal mesothelioma is the second most common type of mesothelioma, accounting for about 20 percent of cases. This kind of mesothelioma is staged either with the peritoneal cancer index (PCI) or an adapted version of the TNM staging system, but there is no widely recognized staging system for this kind of mesothelioma. 

During stage 4 of peritoneal mesothelioma, tumors have spread beyond the peritoneum to the chest wall, abdominal lymph nodes, and other distant organs and tissues. In the PCI staging system, a score between 31-39 indicates stage 4. 

Stage 4 pericardial mesothelioma

Pericardial mesothelioma is a rare type of mesothelioma, accounting for just 1-2 percent of new cases. Because this cancer is so rare, there is no official staging system for pericardial mesothelioma, and it may be diagnosed posthumously. In later stages, cancer may have spread beyond the pericardium to the abdomen, chest cavity, esophagus, and other tissues. 

Stage 4 testicular mesothelioma

Like pericardial mesothelioma, testicular mesothelioma is extremely rare and makes up just 1 percent of cases. Given the rarity of this type of cancer, there is no official cancer staging system for testicular mesothelioma. Oncologists evaluate tumors based on staging guidelines for testicular cancer. Cancer treatment may depend on how far the cancer has spread to distant lymph nodes, organs, and tissues


How doctors make a stage 4 mesothelioma diagnosis

Generally, physicians define stage 4 mesothelioma as disease which has spread from the primary tumor to distant organs, tissues, and lymph nodes. Doctors use three staging systems to describe how far mesothelioma has spread. These systems help oncologists determine your prognosis and treatment course. 

TNM system

In stage 4 of the TNM system, the mesothelioma has spread to both sides of the body. Tumors may appear in the esophagus, lungs, heart, and lymph nodes throughout the body.

Butchart system

In stage 4 of the Brigham system, tumors have grown too large—and have spread too far into other organs—to be removed by surgery.

Brigham system

In stage 4 of the Butchart system, the mesothelioma has spread to parts of the body far removed from the tumor’s point of origin.


Symptoms of stage 4 mesothelioma

Symptoms caused by stage 4 mesothelioma are more noticeable than those caused by any other stage. This is due to the extensive growth of the tumor throughout both sides of the body; at this stage, it can cause shortness of breath, chest pain, stomach pain, or anorexia.

Stage 4 symptoms include:

  • Pleural effusion, the buildup of fluid in the lung’s lining
  • Ascites, the buildup of fluid in abdomen’s lining
  • Cachexia, the severe loss of weight, body mass, and appetite
  • Anorexia
  • Fatigue
  • Fever
  • Night sweats
  • Weight loss

How stage 4 mesothelioma is detected

Around 20 percent of mesothelioma is diagnosed in stage 4. By this stage, patients typically are experiencing symptoms of mesothelioma that lead them to seek medical care and a diagnosis. This differs from earlier stages when mesothelioma may be diagnosed by screening for other issues. 

There is a long (20-60 years or more) latency period between asbestos exposure and cancer development. How quickly cancer spreads depends on the cell type of the tumor and other factors, but advanced-stage cancer tends to grow quickly. 

Mesothelioma may be found in advanced stages as symptoms progress and patients seek care. Oncologists may use X-rays, CT scans MRIs, PET scans, and biopsies to diagnose mesothelioma. 


Learn more about the stages of mesothelioma

Find out more about the other stages of mesothelioma, including the symptoms, treatment options, prognosis and how you or a loved one can get help.


Mesothelioma treatment options for patients in stage 3

The advanced growth of stage 4 mesothelioma may limit your curative treatment options. Your doctor will use palliative treatments to relieve pain and discomfort caused by symptoms of mesothelioma. Depending on your state of health, he or she will most likely treat you with radiation therapy, chemotherapy, or palliative surgery.

Palliative surgery

Palliative care can include minimally invasive surgery to lessen mesothelioma symptoms, ease discomfort, and improve quality of life. These surgeries often involve draining fluid buildup that can cause pain and trouble breathing. They can also include surgery to reduce the size of tumors. 

Palliative surgeries can include:

  • Paracentesis. Drains excess fluid from your abdominal cavity.
  • Pleurodesis. Removes the space between the lung and the chest wall to prevent excess fluid from collecting in the pleura. 
  • Thoracentesis. Drains excess fluid from the pleural cavity.


If you have chemotherapy, your doctor will administer chemotherapy in pill form or intravenously, via IV drip. Both types of chemotherapy are systemic; they travel through your bloodstream, attacking and killing any cancer cell they contact.

Treating patients with stage 4 mesothelioma, doctors have been most successful with two chemotherapy drugs, Alimta (pemetrexed) and Cisplatin. In a recent study, researchers demonstrated that the combination extended the survival rate of patients with advanced mesothelioma from 6 months to an average of 12.1 months. The same study showed that patients who received B12 and folic acid with both drugs had a longer average survival rate of 13.3 months.

Radiation therapy

Radiation therapy is a less common treatment for advanced-stage mesothelioma. However, it may be used to shrink tumors to ease pain, reduce symptoms, and improve quality of life.


Immunotherapy is used to stimulate the immune system to fight cancer on its own.  In particular, the combination of two immunotherapy drugs, Opdivo® (nivolumab) and Yervoy® (ipilimumab), has been shown to improve survival by 50 percent and is an FDA-approved treatment for malignant pleural mesothelioma.  These treatments are now standard cancer treatment options for advanced stages of mesothelioma.

Clinical trials

Your doctor may also enroll you in a clinical trial, where new treatments are developed and tested. In fact, most standard curative treatments—like the highly successful extrapleural pneumonectomy (EPP), and the combination of Alimta and cisplatin—began in clinical trials.

Getting access to cutting-edge treatments gives you a chance to improve your prognosis, and help doctors develop these treatments to help other patients.

Alternative therapies and supportive care

You also have the option of supplementing treatment with complementary and alternative medicine (CAM). These treatments can’t cure cancer, but they may help manage your symptoms.

Common CAM therapies include:

  • Chiropractic care
  • Yoga
  • Physical therapy
  • Acupuncture
  • Breath and relaxation exercises

Your doctor may also recommend supportive care during and after treatment. Receiving it can help ease your symptoms and side effects caused by treatments. Supportive care includes pain medication, exercises, and visits from a registered nurse.

Stage 4 mesothelioma without treatment

For patients diagnosed with late-stage mesothelioma, life expectancy without treatment is shorter than with treatment. Regardless of stage, those who opt not to receive treatment have a life expectancy of around six months. 

With treatment, patients with stage 4 pleural mesothelioma have a medium survival of 12 months. Treatment for cancer at this stage is aimed at easing the painful symptoms of mesothelioma. Before making decisions, discuss all treatment options with your doctors, family, and loved ones.


Prognosis for stage 4 mesothelioma

Stage 4 has the least favorable mesothelioma prognosis and the shortest life expectancy of all stages. In this advanced stage, the spread of cancer limits available treatment options. If cancer has spread to the heart, it can lead to respiratory failure or heart failure. 

Factors that affect your prognosis

  • Cancer cell type. Certain cell types, like sarcomatoid and biphasic mesotheliomas, are very aggressive and metastasize to other areas of the body quickly. Other cell types like epithelioid mesothelioma, are less aggressive.
  • Location & metastasis of tumors. Cancer that has spread to more distant tissues has a worse prognosis than cancer that is more contained. 
  • Overall health. Patients in otherwise good health have a more favorable prognosis than patients with poor health or preexisting conditions.
  • Patient age. Younger patients tend to have a better prognosis than older patients.


Life expectancy and survival rate with stage 4 mesothelioma

Life expectancy refers to how long a patient can expect to live with their cancer. For stage 4 mesothelioma patients, the typical median life expectancy is 12 months, compared to 18 months for stage 3.

Relative survival rate refers to the percentage of people who survive mesothelioma compared to the overall population for a certain increment, often two or five years. For stage 4 pleural mesothelioma, the two-year survival rate is around 24 percent. The five-year survival rate is 16 percent for regional (including some stage 4) and 8 percent for distant (advanced stage 4) pleural mesothelioma, according to the American Cancer Society.

Many factors can impact survival, including age, gender, and overall health. Additionally, aggressive treatment can help to extend life expectancy and improve quality of life. Speak with your oncologist or other specialists about your prognosis to learn more. 


Is stage 4 mesothelioma curable?

There is no cure for any stage of mesothelioma. Mesothelioma caught in an early stage has a better prognosis with more treatment options available compared to later stages. Aggressive treatment and some emerging clinical trials have shown promise in improving life expectancy for end-stage mesothelioma. Work with your oncologist to learn more about available options. 


What to do after your diagnosis

After receiving a stage 4 mesothelioma diagnosis, many patients choose to seek a second opinion. Second opinions can be valuable in understanding your diagnosis and treatment options. You can also ask your doctor to provide information on clinical trials and emerging treatments. At this time, you should also consider options for financial assistance to help with the cost of treatment. 

Maintaining overall health can also improve your prognosis following diagnosis. Many patients see improvements in mood or quality of life by maintaining a healthy diet and exercise regimen. Patients should also lean on guidance from doctors and specialists for ways to improve their quality of life. 

Patients can also consider joining support groups that aim to help patients cope with their diagnosis, connect patients going through similar experiences, and provide perspective on treatment options and managing a diagnosis. 

End-of-life planning with mesothelioma

Stage 4 mesothelioma requires planning to support your family and loved ones, including financial and family care decisions. Documenting your decisions with any necessary legal documents can help relieve anxiety and provide direction for family and loved ones. Planning a palliative care and pain management treatment plan is also essential for late-stage mesothelioma patients.

When it comes to medical care, communicate your wishes to your mesothelioma specialist and other members of your care team. Document your decisions with legally binding documents. Your care plan can include details like your priorities for pain management and what type of end-of-life care you hope to receive (hospital, hospice program, in-home care). 

Patients should also consider financial affairs, including creating a will to specify beneficiaries of insurance policies, bank accounts, possessions, investments, employer benefits, and any other assets. Give passwords and contacts to trusted family members to make sure your loved ones have access to any important documents.

Lastly, plan for personal affairs. Designate a caregiver for surviving children, pets, or other dependents. Provide details on your desired funeral arrangements and contacts who should be notified in the event of your death.

Get support with your mesothelioma diagnosis

You are not alone in your mesothelioma diagnosis. Get the support you need:

You can also speak to a Mesothelioma Advocate who can review your diagnosis and make sure you’re getting the best treatment possible—for free.