Stage 4 Mesothelioma

Expert Fact Checked

This page was medically reviewed by James Stevenson, M.D. on February 6, 2019. For information on our content creation and review process read our editorial guidelines. If you notice an error or have comments or questions on our content please contact us.

James Stevenson, M.D. Thoracic Medical Oncologist

Stage 4 mesothelioma is an asbestos-related cancer that has spread to distant body parts. Patients with this advanced stage of mesothelioma live about 12 – 26 months with treatment. Immunotherapy and surgery-based plans have improved survival and quality of life for some stage 4 patients.

01. Stage 4 Mesothelioma Overview

What Is Stage 4 Mesothelioma?

Stage 4 mesothelioma is the most advanced stage of the asbestos-related cancer. Mesothelioma cancer begins when tumors develop in the lining of the organs. The most common form develops in the lining around the lungs. In stage 4 mesothelioma, the cancer has spread (metastasized) to distant lymph nodes, organs and tissues. This can include the liver and both lungs.

Staging of Mesothelioma

  • Mesothelioma is categorized into four stages based upon the amount and location of tumors.
  • Stage 1 and stage 2 are considered early stages.
  • Stage 3 and stage 4 are considered late stages.

The distant spread of stage 4 mesothelioma may limit some treatment options. But many effective methods, like surgery and chemotherapy, can be used in this stage. Some new and emerging treatments have also increased potential options for late-stage patients. For instance, stage 4 mesothelioma patients have benefitted from immunotherapy in various studies.

Some patients may prefer to receive palliative care rather than aggressive treatment. These care plans focus on improving patient comfort and managing symptoms instead of shrinking tumors.

Patients may choose palliative care out of concern about severe treatment side effects. But recent advances may allow patients to prioritize comfort and quality of life while shrinking tumors. For example, checkpoint inhibitors may boost quality of life and improve survival.

Spotlight: The Best New Treatments for Stage 4 Mesothelioma

Immunotherapies use a patient’s own immune system to find and attack cancer cells. This approach has already improved prognosis for some patients with advanced mesothelioma. Some of the most promising examples of this include:

  • Checkpoint inhibitors: This type of immunotherapy drug makes it harder for cancer cells to evade the immune system. Then, the body can better identify and attack cancer cells. A recent landmark study treated patients with these drugs. Nearly half the study participants had stage 4 pleural mesothelioma. These patients lived about 55% longer than late-stage chemotherapy patients.
  • Combination immunotherapy: Some stage 4 mesothelioma patients have participated in cutting-edge combination immunotherapy trials. In a combined CAR-T cell and Keytruda® (pembrolizumab) study, more than 70% of participants had stage 3 or 4 mesothelioma. Patients in this study lived about two years.
02. Life Expectancy & Survival

Stage 4 Mesothelioma Life Expectancy and Survival Rates

In general, stage 4 mesothelioma life expectancy ranges from 12 to 26 months. Many factors may impact life expectancy, including where mesothelioma develops in the body and the treatment plan. Several treatment options have improved stage 4 mesothelioma survival in studies. Patients can discuss their individual life expectancy and mesothelioma treatment options with their doctors.

Can You Survive Stage 4 Mesothelioma Without Treatment?

Mesothelioma patients who opt out of treatment generally do not live as long as those who opt-in. According to data, pleural mesothelioma life expectancy is about six months without treatment.

Stage 4 patients and their doctors should discuss treatment options. Together they can work toward the patient’s highest priority. This might mean extending survival, boosting quality of life or both.

Stage 4 Pleural Mesothelioma Survival Statistics

In general, stage 4 pleural mesothelioma life expectancy is 12 months. With treatment, survival rates for stage 4 pleural mesothelioma are:

  • 1-year: 52%
  • 2-year: 19%

Recent advances show some forms of treatment may be better than others for stage 4 mesothelioma. Some treatments have been effective at extending life expectancy at this stage.

Examples of these treatments include checkpoint inhibitors and multimodal treatment plans. Multimodal plans are a combination of more than one treatment method.

Depending on treatment types, stage 4 pleural mesothelioma life expectancies can vary.

Stage 4 Pleural Mesothelioma Life Expectancy by Treatment Type

Systemic Chemotherapy 11 months
Checkpoint Inhibitor Immunotherapy 16 months
Multimodal Treatment 23 months
No Treatment* 6 months

*Life expectancy shown for no treatment applies to all pleural mesothelioma patients regardless of stage

Stage 4 Peritoneal Mesothelioma Survival Statistics

In general, stage 4 peritoneal mesothelioma life expectancy is 26 months with treatment. Survival rates for stage 4 peritoneal mesothelioma patients who undergo treatment are:

  • 1-year: 63%
  • 3-year: 40%

Many factors may influence individual life expectancy. For example, patients treated with surgery-based plans may live longer than those receiving just chemotherapy. Stage 4 peritoneal mesothelioma patients can discuss these factors, including treatment options, with their doctors. Patients may have many possible treatment options, including promising new methods.

Stage 4 Pericardial and Testicular Survival Statistics

Pericardial mesothelioma and testicular mesothelioma are less common types of this cancer. Survival rates are not yet known for stage 4 pericardial and testicular mesothelioma. The infrequency of these types means research is limited. Also, unlike pleural and peritoneal mesothelioma, they do not have established staging systems.

General survival times for these types of mesothelioma, regardless of stage, are approximately:

  • Pericardial mesothelioma: 6 months
  • Testicular mesothelioma: About 6 years

A specialist can help estimate the prognosis for a pericardial or testicular mesothelioma patient.

03. Prognosis

Stage 4 Mesothelioma Prognosis

Many factors, including the mesothelioma stage, can affect prognosis. Determining the stage helps doctors estimate prognosis and create a care plan. However, stage is not the only factor affecting prognosis.

Other factors, such as patient age and tumor location, can also impact prognosis. Doctors consider all factors when recommending treatments. For all stages, specialized treatment is the best way to improve a mesothelioma prognosis.

Factors Influencing Stage 4 Mesothelioma Prognosis

  • Biological sex: Female patients tend to have better survival than male patients.
  • Blood counts: Different blood characteristics may have a negative impact on survival. These include high platelet count, high white blood cell count and/or low hemoglobin.
  • Cell type: Epithelioid mesothelioma tends to have better survival rates than sarcomatoid or biphasic.
  • Overall health: Pre-existing conditions or poor overall health may have a negative impact on survival.
  • Patient age: In general, younger patients tend to have better survival than older patients.
  • Tumor location: In general, peritoneal mesothelioma survival is better than other types.

Statistics can help patients understand the typical progression of the disease. Still, each patient’s diagnosis is unique. One example is a recent CAR T-cell clinical trial. One stage 4 pleural mesothelioma patient lived more than 18 months. The patient survived 50% longer than stage 4 patients in a prior study.

An earlier mesothelioma diagnosis may give a patient more diverse treatment options. This is true with stage 4 mesothelioma, too. The earlier treatment begins in this stage, the more options may be available.

04. Symptoms

Stage 4 Mesothelioma Symptoms

Patients with stage 4 mesothelioma may experience general symptoms of the disease like fatigue or fluid buildup. These symptoms may worsen if the tumors spread.

Palliative treatment options may be able to help manage discomfort from mesothelioma symptoms. For example, one common palliative treatment removes fluid buildup in the lungs. This can help ease breathing difficulties caused by the fluid.

Stage 4 Mesothelioma Symptoms*

  • Abdominal pain
  • Chest pain
  • Difficulty breathing (dyspnea)
  • Difficulty swallowing (dysphagia)
  • Fatigue
  • Fever
  • Night sweats
  • Peritoneal effusion (fluid buildup)
  • Pleural effusion (fluid buildup)
  • Unexplained weight loss

*List is a combination of common pleural, peritoneal, pericardial and testicular symptoms

05. Types

Stage 4 Mesothelioma by Type

A mesothelioma patient’s tumor location has a strong influence on their individual experience. For example, pleural mesothelioma tumors form in the lining around the lungs. In later stages, pleural tumors might spread to both lungs.

Peritoneal mesothelioma patients may not have the same experience because their tumors occur in the lining of the abdomen. So peritoneal tumors might spread to abdominal organs, such as the intestines.

Tumor location can also affect survival, symptoms and treatment. By working with a mesothelioma doctor, patients can understand what to expect.

Stage 4 Pleural Mesothelioma

Over the years, doctors have established and improved different staging systems. These systems allow doctors to assess how early or advanced an individual case may be. An effective staging system can help oncologists choose the best treatment for their patients.

Of the various systems, the tumor node metastasis (TNM) staging system is the most common. Doctors typically use this system to evaluate the stage in cases of pleural mesothelioma.

Pleural Mesothelioma Staging Systems

  • The Brigham staging system
  • The Butchart system
  • The TNM system

With stage 4 mesothelioma, the cancer has spread to distant parts of the body. This spreading of cancer, called distant metastasis, may occur in the:

  • Bones
  • Distant organs or lymph nodes
  • Liver
  • Lung that did not have the initial tumor

The 1-year survival rate for stage 4 pleural mesothelioma is about 52%. The 2-year survival rate for stage 4 pleural mesothelioma is about 24%.

Stage 4 Peritoneal Mesothelioma

There is no staging system specifically for peritoneal mesothelioma, though the TNM system is still applicable. Mesothelioma doctors commonly use the Peritoneal Cancer Index (PCI) to stage this type. Other forms of abdominal cancer also use this staging system.

This system divides the abdomen into nine distinct areas. Each area has a score based on the size of the tumor(s) in that area. Doctors add the scores to determine the stage. Stage 4 peritoneal mesothelioma has a PCI score of 31 – 39.

At this stage, tumors have spread outside the immediate area of the peritoneum. Spreading may occur in the:

  • Chest wall
  • Nearby lymph nodes throughout the abdominal cavity
  • Other distant tissues and organs

The 1-year survival rate for stage 4 peritoneal mesothelioma is about 63%. The 3-year survival rate for stage 4 peritoneal mesothelioma is about 40%.

Stage 4 Pericardial Mesothelioma

Like peritoneal mesothelioma, there is no formal staging system for pericardial mesothelioma. Oncologists may use general cancer staging guidelines to determine the stage at diagnosis.

Due to its rarity, detection of this type may occur in later stages. As with other types, stage 4 pericardial mesothelioma has spread to distant areas of the body. Stage 4 pericardial mesothelioma may spread to the:

  • Abdomen
  • Chest cavity
  • Esophagus
  • Other organs and tissues outside of the pericardium (heart lining)

Being an uncommon form of mesothelioma, survival rate is not broken down by stage.

Stage 4 Testicular Mesothelioma

Testicular mesothelioma accounts for less than 1% of all mesothelioma cases. The disease’s rarity complicates the staging process for mesothelioma doctors. In general, doctors stage testicular mesothelioma based on the cancer’s spread to distant:

  • Lymph nodes
  • Organs
  • Tissues

Once diagnosed, testicular mesothelioma patients and their doctors can discuss next steps. These may include staging, treatment and other supportive measures.

06. Treatment

Stage 4 Mesothelioma Treatment

In the past, treatments for stage 4 mesothelioma were relatively limited. Now, advances in research and drug development have opened up new possibilities. Because of these advances, some stage 4 patients may have almost as many options as stage 2 or 3 patients, including:

Can Stage 4 Mesothelioma Be Cured?

There is no cure for mesothelioma. But, patients may extend life expectancy by receiving treatment. Studies and clinical trials continue testing emerging treatments for late-stage mesothelioma.

In 2017, an emerging method study treated late-stage pleural mesothelioma patients.

  • Treatments: All patients had a combination of surgery and photodynamic therapy. Some also received chemotherapy.
  • Median survival: Three years


A common misconception about stage 4 mesothelioma is that surgery is no longer an option. Recent studies show this is not always true for pleural or peritoneal mesothelioma. Stage 4 patients have participated in several studies that involved surgery-based treatment. Stage 4 mesothelioma patients represented between 10% and 30% of the participants in each study.

These studies included the following surgeries as part of a multimodal treatment plan:

  • Pleurectomy/decortication (P/D): This is a common surgical procedure for pleural mesothelioma. P/D removes the lining around the lung (the pleura) and tumors or fibrous tissue from the surface of the lung. The procedure allows patients to keep both lungs but still removes cancerous tissue.
  • Cytoreductive surgery (CRS): This is a common surgical procedure for peritoneal mesothelioma. CRS removes as much cancerous tissue as possible from the abdomen. Often, doctors combine CRS with a heated chemotherapy, called hyperthermic intraperitoneal chemotherapy (HIPEC).

Some patients may prefer milder treatments aimed at increasing comfort and managing symptoms. Palliative options for stage 4 mesothelioma include minor surgeries, such as:

  • Thoracentesis/Pleurocentesis: This procedure removes excess fluid around the lungs (pleural effusion). A doctor uses a needle to drain fluid buildup, reducing pressure on the lungs. This can help patients breathe easier.
  • Pleurodesis: This procedure treats excess fluid around the lungs (pleural effusion) with a slightly different approach. It attempts to prevent fluid buildup by closing the space between layers of the pleura. If successful, this can help prevent breathing issues related to pleural effusion.
  • Paracentesis: This procedure removes fluid from the abdominal cavity. This can help ease feelings of bloating caused by the fluid buildup.

According to research, even palliative treatments can extend life expectancy by months.


Immunotherapy is a newer treatment that has recently become a standard option for mesothelioma. This treatment helps the body identify and attack cancer cells. There are different types of immunotherapy treatments, like CAR T cells and checkpoint inhibitors. Checkpoint inhibitors have approval for treating mesothelioma, while CAR T cell treatment for mesothelioma is still in trial stages.

What are checkpoint inhibitors? Checkpoint inhibitor drugs allow the immune system to fight cancer. In general, immune checkpoints exist to help protect healthy cells. These checkpoints identify cells that the immune system should not attack. Cancer cells can manipulate this immune system process to protect themselves instead. Checkpoint inhibitor drugs block these checkpoints. This helps immune cells identify and attack tumor cells.

Checkpoint Inhibitors for Stage 4 Mesothelioma

One recent, important study treated mesothelioma with two checkpoint inhibitors. The study included more than 300 patients with stage 4 pleural mesothelioma. The drug pair, Opdivo® (nivolumab) and Yervoy® (ipilimumab) provided several notable benefits:

  • Boosted quality-of-life: Opdivo+Yervoy improved patients’ quality-of-life better than chemotherapy.
  • Improved survival: Compared to chemotherapy, Opdivo+Yervoy extended survival by 50%.

These findings represent the best-known survival for intravenous treatments.

Combination Immunotherapy in Advanced Mesothelioma

Doctors have had success in treating advanced mesothelioma with combination immunotherapy treatments. One innovative trial treated pleural mesothelioma with CAR T-cell therapy and Keytruda (pembrolizumab).

More than 70% of the study’s patients had late-stage pleural mesothelioma. One stage 4 patient survived more than 50% longer than stage 4 patients in a prior study. Research continues to study the effectiveness of late-stage mesothelioma cancer treatments.

Multimodal Therapies

Some stage 4 patients may benefit from multimodal therapy, or combining various treatments. This is a common treatment choice for eligible patients. Depending on the stage, some treatment combinations may provide more benefits than others.

For stage 4 mesothelioma patients, doctors routinely combine these therapies:

  • P/D + HITHOC: This multimodal treatment for pleural mesothelioma combines P/D surgery with heated chemotherapy. After surgery, doctors apply hot chemotherapy, called hyperthermic intrathoracic chemotherapy (HITHOC), to the pleural cavity. One study found mesothelioma patients treated with P/D and HITHOC lived about 35 months.
  • CRS + HIPEC: This multimodal treatment for peritoneal mesothelioma combines CRS surgery with heated chemotherapy. After surgery, doctors apply HIPEC to the abdominal cavity. One study found stage 4 patients lived about 26 months after this treatment.

Multimodal therapy may now be more common among stage 4 patients than in the past. Patients should speak with an expert to understand all their options.


Doctors may use intravenous chemotherapy to extend survival and improve quality of life. Some of the most common chemotherapy drugs for stage 4 patients are:

In some cases, doctors may recommend supplementing chemotherapy with a targeted therapy called bevacizumab. Research shows this may extend survival for qualified patients.

Clinical Trials

Stage 4 mesothelioma patients may qualify to take part in clinical trials. These trials investigate promising emerging and experimental treatments. Many stage 4 patients have been part of successful clinical trials.

For example, one recent trial studied photodynamic therapy with late-stage mesothelioma patients. The treatment plan also included P/D and chemotherapy. Patients with stage 4 mesothelioma had a median survival of about 37 months.

Patients and their doctors can discuss which clinical trials may be a good fit for their plan.

Alternative Therapies

Stage 4 mesothelioma patients may consider using alternative therapies alongside standard ones. Alternative treatments are not curative but aim to increase patients’ comfort and manage symptoms. Some alternative therapies can also help manage the side effects of traditional treatment.

Common alternative therapies include acupuncture, massage and herbal supplements. Nutrition professionals and doctors can also explain what to include in a healthy cancer diet. Patients and their doctors can determine which alternative therapies may work with their diagnoses and other treatments.

The stage 4 mesothelioma patient journey

07. Managing Your Cancer

Coping With a Stage 4 Mesothelioma Diagnosis

A stage 4 mesothelioma diagnosis can be emotional for patients and their loved ones. But informational and supportive resources are available to help navigate this journey. These resources may help manage emotional, mental and physical well-being.

Patients may feel overwhelmed by the medical information they’re receiving. Mesothelioma specialists can offer guidance and help explain the details of a diagnosis. Patients can discuss any questions they have with their care team. This can help patients and their loved ones better understand their diagnoses.

Patients may also worry that their life expectancy is set in stone. But with treatment, many stage 4 patients have outlived their initial life expectancies. Mesothelioma survivor stories may encourage patients and their loved ones. Mesothelioma support groups can also provide comfort. Patients may find these groups through their cancer centers, doctors or online.

Each mesothelioma experience and decision is personal, including choices about what comes next. Stage 4 patients may choose to consider future preparations, too. There are many professionals who can guide them through these processes. Patients and their loved ones can find more resources about these topics below.

Resources for Stage 4 Patients: End-of-Life Planning and More

Stage 4 mesothelioma patients and their loved ones have many options to support them. Visit our patient resources page to learn more about how we help mesothelioma patients.