On 25 May 1934, Dr Arnold Rice Rich presented a paper at the annual meeting of the American Urological Association entitled:‘On the frequency of occurrence of occult carcinoma of the prostate’which was subsequently published in the Journal of Urology one year later. 1 At the time, the paper probably garnered the usual polite applause and then was promptly forgotten. When reviewed again in 2006 the observations noted are quite astounding. Based on the information derived from 292 autopsies of men aged 50 years and over performed at the Johns Hopkins Hospital during the early 1930s, Dr Rich noted that (i) multiple small foci of prostate cancer were common findings at autopsy,(ii) most of the tumours were located in the peripheral zone of the prostate mostly laterally and posteriorly,(iii) that the prostate capsule was frequently invaded before the prostate itself had enlarged and (iv) the vast majority of these tumours were unsuspected clinically. Unfortunately it has taken over 70 years before the true significance of these observations has been fully appreciated. Over the years, several other pathologists have made important contributions to our understanding of the prostate and prostate cancer. Rich originally reported a 14% incidence of prostate cancer among the 292 autopsies performed, but tissue sampling frequently consisted of only a single slide. In 1954, Franks2 performed a more systematic analysis of prostate cancer in men undergoing autopsies and noted that 38% of men older than 50 years had microscopic prostate cancer. Sakr et al. 3 extended this work in 1993 and found that as many as 34% of men in their 40s had early evidence of prostate cancer. The clinical importance of these findings has recently been highlighted by the report of Thompson et al. 4 that documented an extraordinarily high incidence of prostate cancer among 2950 healthy men participating in a prostate cancer chemoprevention study comparing finasteride vs placebo. All of these men had PSAs< 4.0 ng/ml at the start of the study and most of these men had PSAs that remained< 4.0 during the seven years of follow-up. Remarkably, 6.6% of the men with a PSA< 0.5 ng/ml had prostate cancer and 26.9% of the men with a PSA between 3.1 and 4.0 ng/ml had prostate cancer. These findings were not based on a step-section analysis at autopsy, but rather using sextant biopsy techniques that sampled only a fraction of the entire gland. These cases appear to be similar to the prostate cancers described by Rich in 1934. He emphasized that ‘in each instance recorded in this paper the growth in question represents a true carcinoma’. The tumours identified in the finasteride study have also undergone careful scrutiny and have been confirmed to be true prostate cancers.

In his article, Dr Rich stated that ‘in each instance the tumor is composed of plump epithelial cells growing irregularly in strands and in acinar formation, and invading the neighboring tissue in a manner characteristic of carcinoma’. His description is typical of the era preceding Dr Donald Gleason’s scoring system. As a member of the Veterans Administation Cooperative Urological Research Group, Dr Gleason evaluated pathology specimens from 2911 men undergoing prostate biopsies and developed the classification system that bears his name. 5 His system is based on the evaluation of glandular patterns under low magnification. Later on, using step-section analyses of prostates removed as part of a radical prostatectomy, Dr John McNeal6 was able to confirm Rich’s original findings that prostate cancers most often originate in the peripheral zone of the prostate and extended his observations by providing …