Shifting Healthcare to a Preventive Model - Andrew Lacy, Founder & CEO of Prenuvo

Shiv Gaglani: Hi, I'm Shiv Gaglani, and I've really been looking forward to this episode because I recently had a personal encounter with the system we're going to be discussing today and was quite impressed with the experience. I'm talking about an advanced MRI screening that can detect solid cancer at Stage 1 and 500 other medical conditions. 

The company behind the screening, Prenuvo, was founded by my guest today, Andrew Lacy, who is a serial entrepreneur, investor, and advisor in a wide range of industries, including science and health.  Prenuvo has locations across North America, finding cancers earlier than normal or that were missed on standard screenings.

So, Andrew, thanks for taking the time to be with us today.

Andrew Lacy: Shiv, it's really great to be here.

Shiv: So, we always like to start by asking our guests to, in their own words, tell us about their backstory, their hero origin story, and what got them interested in medicine and healthcare.

Andrew: Sure. I think my story is not unusual amongst folks out there. I hit my 40s. I'm a serial entrepreneur. I worked too hard. I carried probably a more than normal level of stress and I remember looking in the mirror one day and asking myself, you know, “How do I know I'm okay?” Because we all tend to invest when we're younger to build a better future for the world or for ourselves and what if I'm not going to be around to actually see that future that I'm creating? 

So, I went out and tried to get an answer to that question, and I did a whole bunch of medical tests -- colonoscopy, genetic screening, blood tests, and so on -- and I got these little bits and pieces of answers, but I didn't get one comprehensive answer until I ran into our

founding radiologist who had a clinic in Vancouver, Canada, doing these scans. I went and got the experience, the same experience that you did, and after an hour in this machine, I learned more about my health than the health system had told me my entire life. 

I think most entrepreneurs would sort of recognize this moment when you just kind of feel like you see the future, and for me, seeing the results of this scan felt like I was seeing the future of healthcare. From that moment on, my mission was to figure out how can I take this and bring this to the world. 

Shiv: Yeah, amazing and as I mentioned, I had the opportunity to go to your New York office and get a scan a couple of weeks back. Fortunately, it was all clear, which was icing on the cake, obviously. I was impressed with how professional and high-end the experience seemed, but it seems pretty affordable for a lot of people who are interested in taking their healthcare very seriously. 

So, that's a great backstory. I was wondering, can you give our audience an overview of the actual founding of the company and kind of the evolution of it in the years since you started it? 

Andrew: Sure. So, in the very early years -- this was four-and-a-half, almost five years ago -- we were really focused on just trying to understand if we could even build a market for this screening product. Now looking back, it feels like it should have been more obvious, but we have a health system that is unfortunately very reactive. I think 95% of our $4 trillion that we spend on healthcare in the US is reactive healthcare and so as a system, we're really good at evaluating and figuring out whether an incremental health improvement is going to be a good thing for that system. But actually, we're not really good at sort of challenging some of the core assumptions of the healthcare system, and that's what we had to spend a lot of time doing...beating the pavement, talking to physicians, meeting patients. 

In that first year, we really just built a practice in Vancouver, Canada. From there, we bootstrapped a location in Silicon Valley and that was really key for us as a company, because of course, that's where a lot of investors are. It's one thing to tell investors that you're building the future of health and they should come to Vancouver, Canada to check it out. It's another thing to just come down the road. 

During that, that first year of launching in Silicon Valley, we ended up imaging a vast number of venture capitalist investors and it made it a lot easier for us to raise a Series A round two years ago. Ever since then, we've been expanding and we're now in nine locations and we have another four or five this year to open.

Shiv: Wow, that's amazing, and actually a really good backstory of how you kind of got on the map of Silicon Valley. Before we started recording the podcast, I mentioned that we share an investor. Osmosis' Series A was led by Felicis Ventures, and Aydin Senkut, the founder of Felicis, was on our board. I believe they invested in, was it in your Series A... or at what point did they invest?

Andrew: Well, this is going back a long way. But I met Aydin in 2008, actually through my very first company. He was one of our first angel investors, and that company was the very first iPhone company. It was a company called Tapulous. It was a totally different sector, but the parallels are pretty interesting in that we understood very early on that the iPhone would be a totally new platform. Most investors at the time thought that was just another brand of phone that had very poor market share. So, why would you focus on it? Aydin was one of those investors that really understood, and also had a very visceral reaction to, “Hey, this could be a big platform here. I want to go all in on this.” 

I think similarly, now, ten years later, the fundamental technology that underpins Prenuvo is MRI -- it's a very advanced form of MRI, and we have our own equipment and so on -- but it's MRI. A lot of investors or people out there look at this technology and say, “Well, this has been around for thirty years, and this is about diagnostic use cases.” We looked at it and said, “Actually, there's this screening use case, and maybe it's 100 times bigger.” And again, Aydin was one of those investors who really understood at a visceral level that this could be something transformational in the healthcare space. He and his team have just been wonderful to work with.

Shiv: Absolutely. He's very good at spotting the future, but then also picking winners and helping create that future in so doing. He and our other board member, Alan Patricoff, who started Greycroft, introduced me to 23andMe, with whom we've been working for some years. I understand that Ann Wojcicki, who's the founder of 23andMe -- and who was also on the podcast -- is an investor in your company. Can you tell us a bit about the parallels between Prenuvo and 23andMe that you see? 

Andrew: Sure. I mean, it's so funny because when I was going through business school back in 2005, I believe that was the year that 23andMe was founded. I remember thinking at the time, “Holy cow, this is the coolest company I could possibly imagine.” I never met her. She was like a real role model for me back then. Definitely, it was formative in my desire to want to not only get into startups, but really focus on things that could be incremental. We connected, actually, for the first time around Prenuvo. 

I think one of the things that I found so cool about 23andMe was the idea that you can create

these insights from things that you can't see. In the case of 23andMe, it’s DNA. I feel like that's something that we have in common with that company and Prenuvo in that we are able to identify and bring to you medical insights that you ordinarily wouldn't see if you looked in the mirror. I think there's just something magical about those types of businesses. 

Shiv: Totally. Yeah, it's really interesting and an interesting parallel because most people would get the obvious connection -- which is direct to consumer and making previously very expensive and complicated and just fairly intimidating tests, whether it's genetic or it's MRI -- more accessible. So clearly, that's one of the innovations of Prenuvo is to do that.

I'm wondering, are there parallels also with 23andMe where they obviously have all this massive data set now, have done really cool partnerships with companies like GlaxoSmithKline to do actual drug discovery and development? Do you see any parallels with the number of MRIs you're doing, and while we're at it, we might as well talk about AI as well, because everyone's talking about that now and any applications of AI that you're looking at. 

Andrew: Yeah, it's a really, really great question. I think one of the things that we first of all need to reframe as we think about our health is that our health system sees us as normal until we are diagnosed with some type of advanced disease. The vast majority of people that we image are quote-unquote normal. That doesn't mean that there aren't things going on under the skin, but those things are still very early and so in some ways, we're redefining what normal looks like. What we're learning at Prenuvo is when you start imaging tens of thousands of people in such a comprehensive way, it's really helping further our understanding of early disease progression. 

Of course, you can imagine that as you get better and better at diagnosing disease earlier, there might be interesting targets for drug discovery and there may be new preventive health medical approaches that might be more effective. In fact, it may even help us avoid the medical system altogether and just focus on lifestyle interventions. Because of course, they're much, much more likely to be positive the earlier you address a problem. 

Shiv: Yeah, no, absolutely. I totally get that. So, can you give us any sense of scale? I know you've said nine locations, you raised the Series A two years ago and have done tens of thousands of scans. Can you give us a bit of the highlights of the company's growth and where you see it going over the next several years? Are you going to focus on those nine locations? Are you going to try being ninety locations in the next five years? 

Andrew: Yeah, we're really focusing our energies in two areas. The first area is the clinical exam that you did. We think it's a great exam. So, a lot of our energy and attention is in scaling horizontally, to be able to offer that to as many people as possible, not just in North America, but also around the world. We're doing that by building our own locations, and also by partnering with like-minded businesses that are interested in a preventive health approach to our lives. 

The second thing we're really investing a lot of time in -- you mentioned AI -- is really deepening our understanding of aging. There's sort of a virtuous cycle where obviously the more image data we collect, the more fidelity we get around understanding what is normal and what is abnormal and where you are on that spectrum. The more health insights we're able to deliver back to our members -- and the more insightful the scans are, particularly longitudinally -- the more members we will acquire. That sort of virtuous cycle helps us not only provide a better and better product for people as they come in, but also, obviously, further our understanding of health and science. 

So, what's interesting...when you came in, we captured a whole baseline of information about your body. We calculated organ volumes and muscle volumes, and we segmented your brain, and we did a bunch of things. We're slowly working through an FDA process to be able to expose more and more of that to members like yourself. But the good news is we already collected it. So, when you come in again in a year or two, we will hopefully be able to tell you a lot about what the trajectory of your health looks like. 

Shiv: That's awesome. So, that's a parallel to 23andMe where you take the test, and then years later, if there's a study about a certain single nucleotide polymorphism that's associated with some sort of condition, they'll let you know. Or if they discover a family member of yours or something like that. Do you see something similar? 

Andrew: Yeah, I would love to. Again, probably it's because I'm very enamored by that company and sort of their approach to research. I would love to find ways that we could also do similar things with the image data that we acquire. I remember reading a couple of years ago a bestseller book by Matthew Walker on why we sleep and he looked a lot at the physiology of the brain and there was a study where I think they looked at thirty patients,

and they sort of correlated their sleep patterns with the size of the amygdala. 

Well, you know, when you're imaging tens of thousands of patients, you can imagine just how quickly you could sort of build on that research in a much more comprehensive way, simply by asking people that come in about how they sleep. 

Shiv: That's really great. That kind of opens my mind to far more possibilities, and it makes it very exciting to follow the journey. You've been working on this for a couple years now. What are some of the things that make you most proud, and are there any specific stories you want to share? Because clearly from a visceral level, being able to detect a cancer in someone early on seems like a very gratifying mission. I will interject that you're on the Raise the Line podcast, but probably the most famous podcast I've heard about Prenuvo on is the All-In podcast, and I think the host Jason mentioned someone who heard about Prenuvo through the podcast, got the test, and found something that could have been very bad very early on. So, maybe you can tell us a bit about some of the anecdotes that make you most proud. 

Andrew: Yeah, I mean, I feel so blessed every day because in a former life, I backpacked around the world, like most Australians, and volunteered at Habitat for Humanity building houses and doing various things. The world presents a lot of opportunity to do social good, and, of course, there are also lots of opportunities to build business and it's just a rare possibility to be able to do both at the same time. In the folks that come into our exams, in approximately around 4% of people we find an early-stage cancer in, or an aneurysm, and so there's a potential to really have a lifesaving diagnosis in one in every twenty people. At a certain level, as we grow, that statistic of lives saved becomes bigger and bigger, and it's a core KPI of the company. I mean, we share this in our all-hands meetings every month. But at the same time, it's the personal stories that really hit home hard. 

I remember a woman who didn't smoke a day in her life. At age thirty-eight, we found a Stage one lung cancer that she had successful surgery on a couple of weeks later. I remember a woman who wrote me a letter saying that her mother had died of ovarian cancer and she had had this pain in her abdomen and she would look at her kids and imagine what their life is going to be like without their mother because she surely had the same condition. We imaged her and we found out she had some relatively minor problem with her back. That peace of mind is just incredible. So, I feel so blessed to be able to have patients reach back and tell us a lot about these personal stories. It's the fuel that sort of enables us to keep building seven days a week to move the company forward.

Shiv: Yeah, I can imagine how gratifying that is. I'm sure you have people who at this stage want to work at Prenuvo or already do work at Prenuvo because of their experience as a patient and just believing in the mission so much.

Andrew: Yeah, we have a lot of folks that are either cancer survivors or have had folks, unfortunately, close to them that have passed away from that. Similarly, most of our investors are people that have experience. In fact, all of our investors have experienced the scan firsthand. Many of them are excited to support us not only because they hope that we'll be a good investment for them, but also because I think many of us share a desire for our health system to be more focused on preventive care.

Shiv: Yep. And that's clearly been a theme of our podcast, Raise the Line. You know, we started it because our goal is to train more healthcare professionals more efficiently and then keep them in practice for longer. But the other piece of that is, I've always said there won't ever be enough endocrinologists to treat everyone with diabetes out there. So, we need to also work on the demand side of the equation and get to people earlier before they get Stage 4 cancer and have to go to a surgeon. Let's detect it earlier and then be able to treat it before they need tertiary or quaternary care. 

So, we've had guests on the podcast like Eric Topol, who wrote The Patient Will See You Now, and who has been a really great mentor of mine. We wrote a paper together some years ago as well and he has been an advocate for patient empowerment and engagement...the type of direct-to-consumer healthcare that you and 23andMe have been scaling out. One of the objections that the healthcare community sometimes has is around the false positives or getting people to be the “worried well” where they’ll see something that will cause them more worry than maybe they need to have at that stage in their life. What do you think about that side of the equation? It's an important one to discuss. I know I was considering it when I was going in for the scan of like, “What if I find something and it's not really a thing? What do I do then?

Andrew: Yeah, I think there's probably three comments I would make if I'm able to. The first would be, it sort of reflects a bit of a misunderstanding of what the preventative screening at Prenuvo is doing. We don't often diagnose, for example, cancer. What we do is we look at lesions in the body and we re-stratify these lesions. We work really hard so that the technology can provide a really clear distinction between things you don't have to worry about at all and do nothing about, to things that are a little bit concerning and you might need to do something. 

Second, oftentimes things that are in the concerning bucket are there because they tend to be quite small. So, obviously, the smaller the feature or the lesion, the harder it is to obviously accurately characterize it. What's great about -- and what's really different about --

preventative screening is, from a diagnostic context, is for many of these lesions, the appropriate thing to do is just to come in for another screening in a year or two. We can measure change over time and that's going to tell us more than anything about whether something is concerning or not. 

Then the third thing I think is, you know, anecdotally there's this fear that if patients know a lot about their health, then they're going to freak out or make the wrong decisions, and our experience has been the opposite. People feel empowered. We survey all of our patients between six to twelve months after they do the scan. We ask them, do you feel like you're more in control of your health now than you were before? Do you feel you have more clarity about what's going on with your body now than you did before? And universally those responses are very positive. Anecdotally, we've not really heard of any cases of people quote unquote freaking out about things that they might have learned from the exam. 

Shiv: Totally. That's super relatable. The paternalistic view where you need a doctor to tell you exactly what your body probably knows already never really struck a good chord with me. I think we need more patients to be empowered. I'd rather have a patient who's maybe a bit more worried than they should be, but they care about their body and they care about their health and that of their family than the reverse...someone who doesn't really care about it and doesn't treat their body well.

Andrew: I think another way to look at this sort of more philosophically would be to say if someone is afraid to learn what's going on about their health, that is much less a reflection on companies like Prenuvo and much more a reflection on our health system because our health system has taught us to associate disease with bad outcomes, expensive treatments, scary stuff. In a world where things are caught early, maybe we start to associate it with preventative maintenance, inexpensive lifestyle modifications - much less scary. I think that's philosophically the world that Prenuvo and other preventative health companies are trying to build as we reshape what we believe is healthcare of the future. 

Shiv: That's awesome. That's a really, really interesting way to look at it. And actually a good transition to my next question. As you know, Osmosis is a teaching company. We train healthcare professionals. We teach patients. We teach the general public. We're teaching people about genetics education, a whole concept around -- we call it Year of the Zebra -- where we teach people about rare diseases. If you could snap your fingers and teach any audience some concept or a course, what would it be and why? 

Andrew: Wow. My mind, of course, is always at the challenges that we have as a company, so if my audience were medical students, I think I would want people to think and reflect much more deeply on the question of why don't we have more preventative health in our health system? I think it's rooted in a few reasons. One is the sort of power that's required for a trial around a quote unquote longevity intervention is huge. You need to be able to study millions and millions of people to be able to satisfy a level of clinical proof around these things, and many of the interventions that are being studied or used or practiced are not pharmaceutical drugs that have billion-dollar patentable sort of compounds. They're oftentimes very straightforward and common-sense approaches. 

We might want to ask the question, why is it there's a big longevity trial going on right now around metformin? I don't know if you're familiar with this. It's an NIH funded trial. I think it's great that we're studying that drug and whether it might help us live longer, but what's really interesting about that has been, that took many, many years to get the funding in place to investigate that because there was no patentable molecule at the end of that trial. 

As a society, we are really good at building clinical trials that support incremental improvements through pharmaceutical drugs. But for some reason, we haven't figured out how to do this in the context of preventive health. I think for young kids going through medical school today, I would love it if they could help us solve that problem and maybe change a little bit the way that we think about preventive health away from potentially proven by evidence to sort of evidence-informed. 

An example of that being cancer. I mean, there's certainly no clinical evidence that shows that the higher the disease burden in your body from cancer, the better the outcome. In fact, the reverse is true. But to prove a clinical trial, to prove an intervention saves lives in the field of cancer screening, you actually have to also understand all the other ways people could die for the rest of their lives, and that, unfortunately, is a trial that might take twenty, thirty, forty years. So, you know, I would hope that some people can help us solve this problem for the good of science. 

Shiv: That's very interesting and I do hope that some of our listeners take that seriously because it is a big problem. It's actually something that is also facing another series of researchers we've been having on the podcast in the psychedelic space. Obviously, psychedelics have become very exciting for mental health conditions, but also just human flourishing in general. But clinical trials around psychedelics are very hard because you can't really patent psilocybin or LSD. These compounds have been around for decades or centuries, really, some of them. So yeah, it's a very interesting problem that I think would help multiple areas of healthcare if we were to solve it.

Andrew: Yeah. I would love to speak to people about how we can sort of further our investigation of the science here. 

Shiv: Yeah, we'll put a pin on that and maybe figure out if there's something to follow up on that. You were talking about medical students. Obviously, we have an audience of millions of current and future healthcare professionals. I was wondering, what advice would you have for them about meeting their careers in healthcare during this very interesting time post-pandemic. What does it look like for them?

Andrew: I can speak to the health professionals that I work with every day, and, you know, we now have dozens of radiologists working with us and obviously a lot of MRI technologists that image our patients, and we have nurse practitioners that work with us and speak to patients. I think a lot of people got into medicine because they wanted to help people. The challenge is that the well-worn path leads towards a reactive healthcare system for the most part, where by the time you're seeing a patient, your ability to really affect the outcome is not what you thought it would be when you entered medical school. 

So, what I would encourage people to do is spend some time in companies like us, companies like 23andMe, companies that are focused around functional medicine or mobility or things that are really kind of looking at health differently. I think if you do that, A, you might find that sort of fulfillment that you expected to get when you went into the medical profession, and B, you might help us, again, make our view of healthcare a lot more well-rounded. 

But for sure, a lot of radiologists have joined us and they feel like their career has been renewed because they're finally able to really affect outcomes in a way that they'd hoped to. So, I think that's the promise of all of this wonderful technology coming out of COVID that's focused on preventative health. 

Shiv: Yeah, that's great advice. And it resonates. Actually, the first time I went to a One Medical appointment, I asked the physician there how they like working at One Medical because we keep hearing about burnout and clinicians who spend more time on documentation than they do with patients, etc. They said it was the first time they were working in a health system or health clinic that they didn't feel burned out, that their well-being and health were prioritized just like that of the patients because it was more preventative as opposed to, you know, hospitalist-type sick care medicine. So, that resonates. 

I want to be respectful of your time, so I only had two other questions. The first is, just more broadly, you've had a very successful career as a serial entrepreneur and leader. Do you have any other lessons or advice you want to share with our audience if they want to be innovative and kind of follow in your footsteps?

Andrew: In general, I would say don't wait. Jump into it as soon as you can. I think my philosophy about career and entrepreneurship is sort of like a conventional philosophy about investing your money. When you're young, you should take risks when you're able to and then, you know, as you get further along in your career or you have other responsibilities it gets harder and harder. I think that’s particularly true for people in the medical profession.

I went and studied law. I studied law because I had the grades to study law. I never really thought to myself, do I want to be a lawyer? Is this even interesting to me? I suspect if it's not law for many people, it's medicine. So, I would say ask yourself these questions before you get on that treadmill, because law is kind of a three-year degree but in medicine, you can spend ten years studying before you actually might have the opportunity to look up and say, “Well, actually, is this the thing that I wanted to do?” 

That would be my advice. Take risks early, ask questions and don't do something just because society tells you that that's the thing you should do if you're a smart person. 

Shiv: 100% aligned with all of those. Those are really good. I'll one up each one of those. My last question for you, is there anything else you want our audience to know about you, Prenuvo, healthcare in general? Really it’s an open mic for you.

Andrew: I would just maybe end with a thought that this is such a wonderful time to be in preventive health. I think coming out of COVID, people are aware of the importance of preventive health like never before. We understood that people that struggled with COVID were people that had comorbidities, and oftentimes they didn't even know about them when they sort of turned up in hospital with problems breathing.

At the same time, I think we're also starting to realize that it's really our responsibility to take control of our health. The health system is wonderful for treating problems when they present, but our jobs as individuals, as humans, as folks that want to optimize our lifespan and health span is to really take responsibility for the one life that we have. The analogy I think that most people don't realize -- but when I talk about it, it makes sense -- is in the field of medicine, the only profession that has got it right is dentistry. In America, 150 million people go to the dentist every year, regardless of whether or not they have tooth pain. We understand intuitively if we go to the dentist, well, if we brush our teeth first, then we're less likely to need a filling. But worst case is we'll need a filling. The odds of having a root canal sort of drop to close to zero. And in some ways, what we're trying to do is be just like the dentist, but for the rest of your body. 

Shiv: That's a great analogy. I'll have to send that particular clip to my sister and brother-in-law who are both dentists in Chicago, and they have, I think, six or seven dental clinics at this point so I know they'll love to hear that as well. I think it's a great analogy and one that I never actually put two and two together. That's what we should be striving for in medicine, too. 

So, Andrew, I really want to thank you not only for the time on the podcast, but more importantly, for the work you and your team have done at Prenuvo to make MRI screening more accessible to so many people, including myself. I had, again, a wonderful experience. I recommend our audience check it out and try using it themselves because many of them will be asked by their patients about technologies and offerings like yours. I think it's good for their patients if they have a working understanding of what it's about. So, thanks for taking the time and for everything you've done at Prenuvo.

Andrew: For sure. I appreciate it. It's great to hang out. Look forward to staying in touch, too.

Shiv: Likewise, Andrew. And with that, I'm Shiv Gaglani. Thank you to our audience for checking out today's show and remember to do your part to raise the line and strengthen our healthcare system. We're all in this together. Take care.