The four stages of mesothelioma allow doctors to identify and classify the severity and progression of the cancer at diagnosis. Early stages offer the most hopeful prognosis, while the last stages of mesothelioma often limit the patient to managing pain and improving quality of life.
Mesothelioma staging refers to the process of categorizing malignant mesothelioma according to the extent of the disease in a patient’s body. Staging is a process common to all types of cancer, although specific staging systems are often developed based on characteristics of specific cancers, like mesothelioma.
Four Stages of Mesothelioma
Malignant mesothelioma has four stages that doctors can use to determine cancer progression. During diagnosis, the doctor will determine whether the cancer is stage 1, 2, 3 or 4, with stage 4 being the final stage.
- Stage 1: The tumor is localized on one side of the body and has not spread. Aggressive treatments are typically an option, and patients have an average life expectancy of 21 months or longer.
- Stage 2: The cancer has spread to nearby organs, such as the lung or diaphragm. Treatment options may still be aggressive, and life expectancy is around 19 months or less.
- Stage 3: Cancer cells have spread to nearby tissues and organs and potentially to distant lymph nodes. Treatment options are limited, and average life expectancy is around 16 months.
- Stage 4: The cancer has spread to nearby and distant organs, tissues and lymph nodes. Treatment is usually palliative, and the average life expectancy is around one year.
Mesothelioma staging occurs during diagnosis and does not change with disease progression. If a tumor grows or shrinks in size, the stage remains the same, and doctors reference metastasis or tumor reduction. A variety of diagnostic tests will be used to accurately determine the stage and determine tumor location, size and potential spreading.
Mesothelioma Staging Systems
Due to its rarity, mesothelioma specialists often rely on general cancer staging characteristics to stage the disease, such as those put forth in the American Joint Committee on Cancer’s AJCC Cancer Staging Manual.
Pleural mesothelioma is the only type that has unique staging systems, including the Butchart, Brigham and TNM system. The Peritoneal Cancer Index (PCI) is sometimes referenced when staging peritoneal mesothelioma, looking at tumor size and extent throughout distinct areas of the abdomen and totalling the score to determine stage. The rarest of all mesothelioma types, pericardial and testicular mesothelioma, do not have their own staging system due to a lack of case studies and information on cancer progression.
Butchart Staging System
Proposed in 1976, the Butchart System is the oldest formal mesothelioma staging system. It relies on determining the location of the primary tumor mass in the body for each stage. It does not take into account the size of the tumor, the number of cancer cells present or the overall level of cancer in the body.
Other systems based on the Butchart system have been proposed over the last 30 years. For example, in 1982, Karin Mattson proposed a variation on the Butchart System that offered more concise and precise descriptions of each stage.
Brigham Staging System
In 1993, while working at the Brigham & Women’s Hospital, Dr. David Sugarbaker and several colleagues developed the Brigham/Dana-Farber Cancer Institute staging system (often shortened to the Brigham staging system). The system was initially based on clinical experience with 52 patients and updated in 1998 based on subsequent experience.
The Brigham staging system places an emphasis on surgery as a mesothelioma treatment option. Generally, stage 1 and stage 2 mesothelioma tumors are viable candidates for removal. By the time the mesothelioma cancer reaches the lymph nodes (stage 3) or metastasizes into other areas of the body (stage 4), surgery is no longer a valid option.
TNM Staging System
The Tumor, Nodes and Metastasis (TNM) staging system was developed by French physician Pierre Denoix in the 1940s. Since then it has evolved into a basis for staging many cancers. The first mesothelioma-specific TNM staging system was developed by A. P. Chahinian in the early 1980s.
This system is the most common and is frequently updated according to new research in the mesothelioma field. Doctors look at tumor size and extent, lymph node involvement and metastasis to classify the stage of pleural mesothelioma that a patient has. This system also breaks down the four stages even further to include stages 1A, 1B, 3A and 3B.
Treatment by Mesothelioma Stages
Mesothelioma patients diagnosed at stage 1 or 2 often have the most treatment options available. Early-stage diagnoses usually allow for aggressive treatments while the disease is still localized and the patient is in better health. Treatment options for late-stage diagnoses are often more limited as the cancer has spread to other areas of the body, and patient health may be declining. Existing conditions, age and overall patient health may impact treatment, so patients and their loved ones should discuss their individual case with their doctor to fully understand their options.
Stage 1 Mesothelioma Treatment
Curative surgeries are typically the recommended course of treatment for stage 1 mesothelioma patients, and can typically be aggressive to address as much of the cancer as possible, such as with an extrapleural pneumonectomy or pleurectomy/decortication. Other common treatments include hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal mesothelioma patients, as well as chemotherapy drugs like pemetrexed and cisplatin or radiation therapy.
Stage 2 Mesothelioma Treatment
Patients with stage 2 mesothelioma typically have a wide range of treatment options available to them. Multimodal treatment is common, consisting of a combination of surgery, chemotherapy and radiation, but may not be an option for all patients. Surgical resection may depend on any nearby metastasis and patient health. Clinical trials may also be available for eligible patients to slow disease progression or manage pain.
Stage 3 Mesothelioma Treatment
Treatment options for stage 3 mesothelioma patients are primarily palliative and focused on providing patient comfort and improving quality of life. Systemic chemotherapy may be used to kill cancer cells, while radiation might be used to shrink tumors to relieve pressure on internal organs. Surgical procedures such as pleurocentesis or paracentesis are often used to drain fluid buildup and alleviate symptoms like difficulty breathing and chest or abdominal pain.
Stage 4 Mesothelioma Treatment
Due to metastasis of the cancer and declining patient health, surgery, chemotherapy and radiation are not commonly offered to patients at stage 4. Treatment plans for stage 4 patients are primarily composed of palliative treatments, aimed to improve quality of life and reduce symptoms as much as possible. Patients with stage 4 mesothelioma may also be interested in participating in specialized clinical trials offered at leading cancer hospitals and centers.
Author: Linda Molinari
Editor in Chief, Mesothelioma Cancer AllianceRead about Linda
Reviewer: Annette Charlevois
Patient Support CoordinatorRead about Annette
American Cancer Society. Malignant Mesothelioma Stages. Updated December 2017.
American Cancer Society. Survival Statistics for Mesothelioma. Updated December 2017.
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