Understanding Stage 4 Mesothelioma

In stage 4, the mesothelioma has spread throughout the chest and possibly outside the chest cavity. Symptoms become severe at this stage because tumors cover vital organs and restrict the lungs and heart. Tumor-removing surgery is not an option at stage 4. Chemotherapy extends survival and clinical trials offer experimental therapies such as immunotherapy.

Stage 4 pleural mesothelioma is primarily treated with chemotherapy to extend survival. Emerging therapies — such as immunotherapy and anti-angiogenic therapy — may be recommended to control cancer growth and relieve symptoms.

Palliative therapies are also used to control pain, reduce symptoms and improve quality of life.

Life expectancy for stage 4 mesothelioma depends on the patient’s response to treatment and how fast tumors continue to spread. Patients who decide against treatment live an average of six months, while those who undergo treatment survive about one year.

Stage 4, or end-stage mesothelioma, is considered terminal. However, treatment breakthroughs have helped some people outlive their mesothelioma prognosis by years.

What are the Symptoms of Stage 4 Mesothelioma?

The end stages of mesothelioma symptoms are severe. Difficulty breathing and swallowing can lead to distress, weakness and sleep problems. Some patients may experience blood issues such as low red blood cell count (anemia) and high platelet count (thrombocytosis).

Common Symptoms of Stage 4 Mesothelioma include:

  • Difficulty breathing
  • Coughing and wheezing
  • Pain in the side of the chest or lower back
  • Fatigue
  • Fever
  • Trouble swallowing
  • Severe weight loss
  • Muscle weakness
  • Excessive sweating
  • Swelling of the face and arms

What is the Prognosis and Life Expectancy?

Unfortunately, the prognosis for most stage 4 mesothelioma patients is poor.

  • Without treatment, the average life expectancy is around six months.
  • With treatment, most patients live around 12 months.

The five-year survival rate for advanced-stage pleural mesothelioma is 7%, according to the Surveillance, Epidemiology and End Results Program of the National Cancer Institute.

However, these averages cannot predict how long each individual patient will live. For example, a small percentage of patients have slow-growing tumors. Some of these patients live for years with stage 4 mesothelioma.

Some patients respond well to innovative therapies such as immunotherapy. For example, sometimes only one mesothelioma patient in a clinical trial will respond well to a drug or therapy. The drug may fail most patients in the trial, but a lucky few will see positive results.

What Are My Treatment Options?

Treatment options for stage 4 pleural mesothelioma include chemotherapy, palliative surgery and radiation therapy. Clinical trials and compassionate use programs offer immunotherapy and anti-angiogenic therapy. Palliative therapies are available to control pain, reduce symptoms and improve quality of life.


Chemotherapy can help stage 4 mesothelioma patients live longer. It also reduces symptoms such as difficulty breathing and chest pain.

The most common and effective chemotherapy regimen for pleural mesothelioma is a combination of Alimta (pemetrexed) and cisplatin.


Stage 4 mesothelioma is considered unresectable, which means unable to be removed by surgery, because of advanced tumor spread. Tumor-removing surgery isn’t possible at this stage because the cancer is too widespread to be removed.

Even attempting such an aggressive surgery could shorten the life span of a stage 4 patient. However, palliative surgeries are available that aim to improve symptoms rather than remove tumors.


This minor surgical procedure drains fluid from the pleural space that lines the lungs. It relieves pressure around the lungs to improve lung function. Patients breathe easier after this procedure, but they may require a repeat thoracentesis if the fluid returns.


This procedure takes the thoracentesis surgery a step further by closing the pleural space. Surgeons fuse the two layers of the pleural lining together, which effectively prevents fluid from accumulating.

Radiation Therapy

Radiation therapy can help stage 4 patients with painful chest wall tumors.

Some tumors that spread to the chest wall cause severe pain. Radiation therapy can shrink these tumors, which helps reduce pain caused by pressure against nerves and sensitive organs or tissues.

Clinical Trials

Some stage 4 patients may qualify for clinical trials testing the latest cancer treatments.

These research studies are a great opportunity for patients to get access to promising immunotherapy drugs such as Keytruda (pembrolizumab) and Opdivo (nivolumab).

Other emerging treatments include anti-angiogenic therapy and gene therapy. Anti-angiogenic drugs stop tumors from forming new blood vessels, which stops cancer cells from spreading. Gene therapy involves modifying a patient’s cancer genes to fight cancer from within the body.

Doctor speaking with an older woman
Get Help Finding a Doctor
Mesothelioma specialists play critical roles in improving prognosis

Palliative Care

Palliative care aims to control pain, alleviate symptoms and improve quality of life.
  • Medications are prescribed to reduce pain and swelling. Other medications may be given to improve breathing, assist sleep or reduce anxiety.
  • Some patients require supplemental oxygen in the end stages of mesothelioma symptoms.
  • Physical therapy or occupational therapy may be recommended to offset muscle weakness and make daily living easier for the patient. Respiratory therapy helps patients breathe easier.

Life Expectancy Without Treatment

The average life expectancy for stage 4 mesothelioma without anti-cancer treatment is six to eight months.

Patients who decide against anti-cancer treatment, such as chemotherapy and immunotherapy, may still elect palliative therapies to improve symptoms and maintain quality of life.

What to Expect

Patients in mesothelioma’s final stages can expect to experience an increase in symptoms. More symptoms will develop, and their severity will increase as the disease progresses.

  • Breathing becomes more difficult. Supplemental oxygen and respiratory therapy can help.
  • Swallowing becomes increasingly difficult. Pulmonary aspiration of fluid or food becomes a concern in the final stages.
  • Weakness and fatigue become extreme. Some patients require help getting in and out of bed and around the house.

As the cancer progresses, patients will need more care and assistance. Working with a palliative care specialist can help maintain quality of life, and so can working with a hospice provider.

Some families hire a professional caregiver or home health aide to help provide medical care and handle other caregiving duties.

Stage 4 Survivor Stories

A stage 4 diagnosis and the survival statistics that come with it can be devastating. But many mesothelioma survivors have beaten the odds and far outlived their initial prognosis.

  • Andy Ashcraft, mesothelioma survivor
    Andy Ashcraft
    Andy Ashcraft survived for seven years after his stage 4 diagnosis. He enrolled in a clinical trial where he saw positive results taking the immunotherapy drug Amatuximab (MORab-009). He later turned to cannabis oil, which he credited for controlling his tumor growth and managing symptoms.
  • George Schottil, mesothelioma survivor
    George Schottl
    This Swedish mesothelioma survivor was given just three to six months to live after his stage 4 diagnosis. George Schottl went on to survive nine years thanks to surgery, chemotherapy and a positive outlook.
  • Lannie Chitwood, mesothelioma survivor
    Lannie Chitwood
    Doctors gave Lannie Chitwood a few months to live. He didn’t let that stop him. Chitwood is a rare example of a stage 4 patient being eligible for and finding success with an aggressive surgery. He underwent an extrapleural pneumonectomy, followed by radiation and chemotherapy. Chitwood survived 10 years after his 2007 diagnosis, spending much of that time fishing, traveling and cherishing moments with his five grandchildren.