Gov. Larry Hogan (R), who publicly battled cancer himself three years ago, sent “heartfelt prayers” to his longtime friend and sometime nemesis “on what I know must be one of the toughest days he’s faced.”

Miller teared up while going over basic procedures in the Senate chamber, and again at a panel discussion on economic development. He then got a pat on the back and a private word of comfort from House Speaker Michael E. Busch (D-Anne Arundel), who survived a liver transplant in 2017 and heart bypass surgery last year.

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“Well, it’s very sad. Mike Miller has always been a bigger-than-life figure in the legislature,” said Busch, who has known Miller since the 1980s. “We all go through our health problems. I know what it’s all about. But knowing Mike Miller, he’s going to beat this, and he will keep a good sense of humor to him and continue to run the Senate.”

In a written statement, Miller said he has struggled since early last year with “significant” back pain, following hip and knee replacement surgery. Attempts at pain management “did not address the debilitating pain issues,” the statement said.

He was diagnosed with cancer in July and given medication, which failed to halt the malignancy. On his doctor’s advice, Miller said, he started chemotherapy treatments, which will last through the 90-day legislative session that began Wednesday.

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“I fully intend to fight this disease, as so many have, and to fully carry out my Senate responsibilities,” Miller’s statement said. “There are not enough words to thank you all for your continued support and service to our great state of Maryland. Now, let’s get to work.”

Jake Weissman, Miller’s chief of staff, said the cancer was advanced and had metastasized, meaning that it has spread elsewhere in his body. Weissman said Miller, who did not take questions Thursday, issued the public statement and made other information available because he wanted to be open and transparent about his diagnosis.

A cancer expert who read the statement said the initial medication Miller referred to likely was androgen deprivation therapy, a hormonal treatment designed to starve prostate cancer of the testosterone it needs to grow.

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Keith Kowalczyk, director of urologic oncology at MedStar Georgetown University Hospital, is not Miller’s doctor and is not involved with Miller’s care. But he said that when cancer spreads beyond the prostate gland despite the hormonal treatment, doctors turn to chemotherapy in hopes of containing it.

“We unfortunately cannot cure metastatic prostate cancer, but we can stabilize it,” Kowalczyk said, adding that there “are still many options,” including immunotherapy and newer anti-androgens.

Weissman said the 76-year-old senator had not gotten regular prostate screenings in recent years, but did when he was younger. The U.S. Preventive Services Task Force, a federal advisory committee, does not recommend such screening for men over the age of 70 because levels of prostate-specific antigen (PSA) — which may indicate prostate cancer — rise naturally through life, so elevated levels in older men do not necessarily point to cancer.

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The longest-serving Senate president in the country, Miller has been a towering figure in state politics and is known as a kingmaker, especially in his native Prince George’s County and Southern Maryland. He has guided the state through dozens of defining moments, including the legalization of casino gambling and same-sex marriage and the end of the death penalty.

Miller grew up the eldest of 10 children in then-rural Clinton, where his family has operated a general store for generations. Raised a Democrat, he first became interested in politics in the summer of 1962, when he worked as a driver and aide for a neighbor, Republican gubernatorial candidate Frank Small Jr.

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He was elected to the House of Delegates in 1970 and the Senate four years later.

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A practicing Catholic, Miller is more conservative than many of the Democrats he leads. He voted against legalizing same-sex marriage in 2012, but nonetheless paved the way for the law to pass, saying his views were “on the wrong side of history.” He also stood in the way of full repeal of Maryland’s death penalty for years before letting it go through.

“It goes without saying that he’s a political genius,” U.S. Rep. Jamie B. Raskin (D-Md.), a former state senator, told The Washington Post last year. “He has been open to a lot of the dramatic political changes of our time, even when it cuts against every fiber of his political upbringing.”

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Miller’s cancer diagnosis and expected absence during parts of the legislative session comes at a critical time for the Democratic-majority General Assembly, which experienced a generational and ideological shift last year when several veteran lawmakers retired or lost primary challenges.

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Following the ouster of some of his key lieutenants, Miller set to work forging bonds with their mostly much-younger successors He gave personal shout-outs to all of them when the legislature convened this week.

But progressive advocates still talk openly about the need for a new, more liberal agenda at a time when Democrats are energized by opposing President Trump and Republicans in Congress.

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On Thursday, the Senate gallery and floor were packed with Miller well-wishers from across the political spectrum, including state Health Secretary Robert R. Neall and budget director and cancer survivor David R. Brinkley, both former Republican senators; and former Miller chief of staff Victoria L. Gruber, currently executive director of the General Assembly’s Department of Legislative Services.

“We were punched in the gut today,” said Senate Minority Leader J.B. Jennings (R-Baltimore County), describing Miller as a “bear” with “a soft side” who is loved on both sides of the aisle.

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“A lot of people have picked fights with him and lost,” he said of Miller. “Cancer picked a fight that Mike Miller is going to win.”

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Miller received his first chemotherapy treatment Tuesday, missing the Democrats’ annual pre-session luncheon, where he normally works the room and makes a speech. He walked with a cane and appeared to be weak Wednesday, when he was unanimously elected to lead the Senate for the 33rd year in a row.

In a nod to the historic number of women elected in November, Miller picked Sen. Katherine A. Klausmeier (D-Baltimore County) as president pro tem — the second woman ever to serve in the position. His new team also includes Sen. Nancy J. King (D-Montgomery) as chairwoman of the Senate Budget and Taxation Committee and Sen. Guy J. Guzzone (D-Howard) as majority leader.

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Klausmeier, whose eyes filled with tears as she talked about her longtime friend Thursday, is tasked with filling in for Miller when he is absent. She will do so Friday morning, when Miller is scheduled for his next chemo treatment.

Rachel Chason contributed to this report.