Prostate Cancer Legislation Poses Dilemma for Dole : Congress: He had led fight against the disease. But Medicare coverage plan comes amid cutbacks and may call attention to GOP candidate’s health.

Not long ago, Senate Majority Leader Bob Dole launched a personal war against prostate cancer, the disease that kills 40,000 American men a year. The Kansas Republican spoke frankly about his recovery from the disease--and struggled to widen the government’s commitment against it.

Today, the policy fight Dole started so resolutely is nearing fruition. Legislation now pending in Congress, which supporters hope to attach to the massive federal budget-balancing measure, would guarantee coverage under Medicare for an acclaimed, yet controversial, prostate cancer blood test.

It is a test that Dole has credited with saving his life.

But Dole faces a double quandary: First, requiring the government to pay for the prostate test would cost at least $2 billion a year--at a time when Dole and the rest of the Republican congressional leadership are pledging to reduce Medicare’s growth by billions of dollars each year. Broad use of the test also is fiercely debated by health experts, who disagree over whether it would cause more harm than good.

Secondly, taking a high-profile role in pushing the legislation--while consistent with Dole’s past efforts--would draw renewed attention to his age and health.

Dole, 72, would be the oldest man elected to a first presidential term, and the only one to win after acknowledging having had cancer. While Dole has not concealed either his age or his 1991 cancer surgery, neither has he called attention to them. Polls indicate that his age and health remain danger areas for his campaign.

As a result, the fate of the prostate cancer legislation has become an example of the pressures Dole faces as he balances his job as Senate majority leader with his pursuit of the job he wants--president.

According to congressional aides and friends, Dole has decided that because of the sensitivity it poses for his candidacy, he will publicly say as little as possible about prostate cancer.

Dole was unavailable for comment, and his spokesman declined to speak on his behalf. Others who have talked with Dole about the subject, however, provide a consistent explanation.

“Right now, he’s got an election. . . . I think he doesn’t want to call too much attention to the fact that he is a prostate cancer [survivor],” said Dr. William J. Catalona, a leading prostate surgeon at Washington University in St. Louis who has conferred with Dole and was among the first to call for the expanded Medicare coverage. “But he’s already done a lot. Behind the scenes, he’s 100% behind us.”

“The only reason he is not getting out front is because he doesn’t want people to make it a presidential issue,” added a congressional aide who is working to pass the legislation.

The prostate cancer legislation is being sponsored in the Senate by a handful of lawmakers who, like Dole, are survivors of the disease. Among the backers are Republican Sens. Richard C. Shelby of Alabama and Ted Stevens of Alaska.

“[Stevens] and Sen. Dole jokingly refer to themselves as the ‘prostate cancer poster boys’ of the Senate,” said Mitch Rose, Stevens’ spokesman. Dole, in addition to his efforts to change federal policy, has hosted meetings of a prostate cancer support group, sharing his experiences of recovery.

Supporters of the proposed Prostate Cancer Diagnosis and Treatment Act of 1995 have sought to attach parts of it to the various versions of the overall federal budget bill that are now the subject of intense negotiations between the White House and congressional leaders.

The legislation now pending in the Senate and the House would expand Medicare’s coverage and pay for the blood test, known as PSA, or prostate specific antigen, for all men 65 or older, regardless of whether they have symptoms. Those found to have an elevated level of PSA, an enzyme found in the prostate, are believed to be at greater risk.

The bill also would require Medicare to cover certain oral drug treatments for patients who have advanced prostate cancer. An estimate by the Congressional Budget Office shows this provision would benefit two drug manufacturers, whose prescription treatments are not now paid for by Medicare and cost $1.2 billion over seven years, in addition to the $2-billion annual cost for PSA blood tests.

The contrast between trying to cut the growth in Medicare’s overall costs while providing new coverage for prostate cancer drug treatments has not gone unnoticed. “I think this amendment has a virtuous purpose,” Sen. John D. (Jay) Rockefeller IV (D-W. Va.) said in October when the Senate unanimously voted to attach the prostate drug coverage to the federal budget bill.

“But I would be very surprised, quite frankly, if we can in Medicare buy a single new aspirin--much less prostate cancer and breast cancer remedies” with the Medicare growth restraints Republicans have proposed, he added.

The PSA test itself is controversial, not only because of its cost, but also because some health experts believe that it could do more harm than good.

Prostate cancer primarily affects men older than 60. In many cases, however, those men carry tumors that are not aggressive and do not spread beyond the prostate. But wide-scale PSA testing, critics say, would cause many of those men to seek surgery--exposing them to side effects that can include impotence, incontinence or, in some cases, death.

Among those skeptical of the broad application of the test are experts at the National Cancer Institute. Dr. Barry Kramer, an associate director of the institute who is overseeing a long-term prostate study of 35,000 men, warned Dole at a March 1992 meeting “that the risk of dying from [unnecessary] clinical treatment for prostate cancer is higher than the risk of dying from the disease itself,” according to a summary of the meeting prepared by the National Cancer Institute and obtained under the Freedom of Information Act. Kramer estimates it would cost $12 billion to administer the PSA test to most American men older than 50.

A group of cancer specialists presented similar conclusions in a report this year to Congress’ Office of Technology Assessment.

“The policy question about whether to provide a [Medicare] benefit for PSA screening depends on whether the large early investment needed for such a program is warranted, at a time when a legitimate question can be raised about whether such screening does more harm than good,” wrote Dr. Michael J. Barry of Harvard Medical School, summarizing the conclusions of the report.

Assuming a typical percentage of follow-up procedures, Barry estimated that annual PSA testing of men 65 and older would cost Medicare at least $2 billion.

“Inflicting incontinence and impotence on large numbers of men, and spending large numbers of health care dollars in an era where growth in health care costs needs to be constrained, seems irresponsible,” Barry wrote.

Yet even those who oppose expanding Medicare’s coverage do not dispute that the PSA test is unsurpassed at tracking the status of prostate cancer once a tumor has been diagnosed.

Proponents who are urging Dole and the Congress to approve the increased Medicare coverage say the test is needed for early detection of the disease and to prevent unnecessary deaths. Backed by celebrities who have contracted the disease, they note that prostate cancer has trailed other maladies, including breast cancer, in winning federal funding.

“We want the same [government] consideration for prostate cancer as for breast cancer,” said Thomas W. Bruckman, chief executive officer of the American Foundation for Urologic Disease, noting there is now a 3-to-1 disparity in federal spending.

The American Cancer Society estimates 244,000 cases of prostate cancer will be diagnosed this year, and that a man has a 1-in-6 chance of developing the disease. For men, it is the No. 2 cancer killer.

When it comes to finding government funding for the fight against prostate cancer, Dole in the past has been at the forefront.

His position on PSA testing has been consistent with his own experience with the disease. He credits the test for detecting his cancer at an early stage. He lent his name to mobile PSA-test labs at the Kansas State Fair and the 1992 Republican National Convention that provided free screening to thousands. He introduced or co-sponsored legislation that would have provided millions of federal dollars for PSA testing in the United States and abroad.

Dole’s advocacy also has paralleled the wishes of drug manufacturers, who stand to gain from the increased testing for and treatment of prostate cancer.

Dole has enjoyed the manufacturers’ backing during his Senate campaigns and his 1988 run for the presidency. Records show that Dole’s No. 2 donor among drug makers has been Schering-Plough Corp., one of the two companies whose prostate drugs would be eligible for Medicare coverage under the pending legislation. Dole’s campaigns have received $27,000 since 1988 from Schering-Plough or its executives.

Dole also has a personal financial stake in the firm: His Senate income-disclosure statements show he purchased between $1,000 and $15,000 of Schering-Plough stock in 1993 and 1994.

Now Dole’s old allies are watching and hoping that he will be able to use his crucial position as majority leader to help finally win their fight for the expanded government health coverage.

“We’re going to prevail on this,” said Catalona, the Washington University surgeon. “When he can come forward, he will.”

Times staff writer Dwight Morris contributed to this story.