Yes, the PET-CT report dated April 13 th 2016 was included in the structured summary reviewed by a medical oncologist at Tata Memorial Centre.

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1 May 9 th 2016 Dear Mr. Ramesh Srivastava, Thank you for reaching out to Tata Memorial Centre for an expert opinion in regard to assessing your treatment options. Navya is pleased to offer this online consultation service for Tata Memorial Centre. We had converted your case reports submitted to us on April 16 th 2016 into a structured summary to be reviewed by a medical oncologist in the Uro-Oncology Disease Management Group at Tata Memorial Centre. The report from that consultation, including the expert opinion of the medical oncologist, was submitted to you on April 26 th Navya is pleased to interpret for you the expert opinion from the medical oncologist and the radiation oncologist, and provide following information. For your convenience, we have reproduced your questions in italics and within quotes. 1. I believe based on conversation with you that interpretation on PET CT scan report was done by expert doctors and forth & last point of PET CT report (as it was not mentioned in your case history) was also taken care while forming the opinion and treatment plan? Yes, the PET-CT report dated April 13 th 2016 was included in the structured summary reviewed by a medical oncologist at Tata Memorial Centre. 2. It is recommended to continue hormone injection with Goserilin (10.8 mg) at every three months along with tablet Bicalutamide 50 mg daily till the disease progression or limiting toxicity. How one can know disease progression has started or not? What is limiting toxicity and how one can know that it has reached? After completion of every two to three months of the ongoing hormone therapy with Goserilin 10.8 mg, response should be assessed with diagnostic tests such as ultrasound/ct scan of chest/abdomen/pelvis, or PET CT scan of the whole body, along with bone scan and Prostate Specific Antigen test, to assess for any disease progression. Additionally, any side effects of Goserilin that are serious enough to prevent an increase in dose or level of Goserilin indicate dose limiting toxicity. In other words, if the side effect of the therapy starts to prevent safe administration of the therapy, dose limiting toxicity (also known as dose limiting side effects) has been reached. Your treating Navya Inc does not diagnose, treat, give orders, or have the ultimate authority over the care of any individuals. Page 1

2 oncologist(s) are best suited to assess for dose limiting toxicity during the course of your treatment. We hope that the information provided to you has adequately answered your questions and resolved your concerns. Please do not hesitate to write to us or call us with any questions. Sincerely, Gitika Srivastava Navya Inc does not diagnose, treat, give orders, or have the ultimate authority over the care of any individuals. Page 2

3 CASE SUMMARY Navya ID 1545fu Expert Opinion ID 3523, Mr. Ramesh Chandra Srivastava Current Diagnosis: Metastatic Prostate Cancer Age: 64 Years Old Gender: Male Past Medical History: Hypertension (High BP) Past Medical History: Diabetes - DM Type 2 Complaint(s): Frequent urination for two years, dysuria for a year [November 2015] PSA: 11.1 [May 2014] PSA: [September 12th 2015] Digital Rectal Examination (DRE): Left base lateral nodule, CT2a, grade I [October 2015] PSA: 14.6 [October 7th 2015] MRI Prostate: 5.4*4.0*3.9cm prostatomegaly with altered signal intensities & hyperintense with capsular bulge- likely extracapsular extension in the mid gland laterally. Adjacent Rt puborectalis muscle fat loss. [November 17th 2015] PIRADS: 5 Diagnosis Made By: Slide/Block Review- Transrectal Ultrasound (TRUS) Guided Needle Biopsy- Bilateral Prostate [November 17th 2015] Malignant Disease: Adenocarcinoma Gleason Score: 8 (4+4) Note: 80% prostatic cores involving Rt side and 5% prostatic cores involving Lt side US Abdomen/Pelvis: Normal [October 9th 2015] Navya Inc does not diagnose, treat, give orders, or have the ultimate authority over the care of any individuals. Page 3

4 Bone Scan: Sacrum body faint focal uptake; Rt iliac, acetabulum, ischium & Rt pubic bone increased foci tracer accumulation. Suggestive of skeletal metastases. [November 18th 2015] Met: Bone: Yes PSA: 17.6 [December 2015] Prior Chemotherapy #1: Timing Chemotherapy Start Date End Date Response Palliative/Metastatic D- D(75)_q3w*6 December 1st 2015 March 22nd 2016 Complete Response Prior Hormone Therapy #1: Timing Hormone Therapy Treatmen t Start Date Treatmen t End Date Respons e Palliative/Metastati Goserilin(10.8)_q3m* December March Complete c 3 14th th 2016 Response PSA: 0.06 [March 2016] Navya Inc does not diagnose, treat, give orders, or have the ultimate authority over the care of any individuals. Page 4

5 Prior Hormone Therapy #2: Timing Hormone Therapy Start Date End Date Palliative/Metastatic Bicalutamide(50)_qd- December 1st 2015 Ongoing PSA: 0.06 [April 4th 2016] FDG-PET CT: Non FDG uptake Rt ischium, Rt ischiopubic ramus, Rt acetabulum & Rt pubic bone sclerotic lesions-?healed metastases; non FDG uptake subcm B/L lower lung nodules-?benign; no malignant disease in rest of body including prostate [April 13th 2016] Bone Marrow (Hematologic) Function: Adequate [April 4th 2016] Kidney (Renal) Function: Adequate [April 4th 2016] EGFR: Liver (Hepatic) Function: Adequate [April 4th 2016] Alkaline Phosphatase: Heart (Cardiac) Function: Adequate [November 2015] LV Ejection Fraction: 55% Functional Status- ECOG Score: 0 General Condition: Patient is capable of self care, can bathe, clothe, eat, climb stairs and walk around, frequency of urination poor control on holding urge of urinating Navya Inc does not diagnose, treat, give orders, or have the ultimate authority over the care of any individuals. Page 5

6 Navya is a Cambridge, MA based company with offices in Bangalore, India. Navya is founded by graduates of Harvard University, MIT Sloan School of Management, and the Stanford School of Medicine. Navya s innovative and scalable decision making system is a technology powered solution for complex medical questions. Navya s software solutions are efficient engines to gather and synthesize individual goals of care, evidence specific to an individual medical case, and expert opinion, for evaluating treatment alternatives. Navya s goal is to assist in bringing clarity to the complexity of evaluating treatment alternatives. Navya s system collects the best available information and expertise from several worldwide sources relevant to a specific previously diagnosed medical case and assesses treatment decisions. For more information, please visit If you have any questions, please call or gitika@navyatech.in Navya, Inc does not diagnose, prescribe medication, treat, or give orders, nor does Navya have the ultimate authority over the care of any individuals. Navya does not provide medical advice nor does its products, services, systems, projects, or programs constitute the practice of medicine, nursing, or any other health care profession. Any information provided by Navya as a result of use of Navya s products, services, systems, projects, or programs is being provided solely for educational and informational benefit and should not be considered diagnosis, treatment or a substitute for professional medical advice. Use of Navya s products, services, systems, projects, or programs does not establish a doctor-patient relationship. Navya encourages that individuals or patients using Navya s products, services, systems, projects, or programs share any reports or other information generated by the use of Navya s products, services, systems, projects, or programs with their treating health care provider. Use of Navya s products, services, systems, projects, or programs is voluntary and any information communicated as a result of the use of Navya s products, services, systems, projects, or programs is not intended to be, nor implied to be, and cannot and should not be used as a substitute for professional medical advice, diagnosis or treatment. Navya s products, services, systems, projects, or programs are limited to the provision of consultative services with respect to known or previously-identified condition and neither Navya, nor its employees, consultants or agents with whom it contracts will diagnose, treat, give orders, prescribe medications or have any authority over the care of any individuals. Navya s products, services, systems, projects, or programs will not involve any direct face-to-face encounters or physical examinations. Accordingly, individuals using Navya s products, services, systems, projects, or programs are encouraged to share and discuss any information provided as a result of use of Navya s products, services, systems, projects, or programs with their treating physician. The individuals or patients using Navya s products, services, systems, projects, or programs will be the ultimate decision maker over their own care. Navya Inc does not diagnose, treat, give orders, or have the ultimate authority over the care of any individuals. Page 6

7 INDIVIDUALS OR PATIENTS USING NAVYA S PRODUCTS, SERVICES, SYSTEMS, PROJECTS, OR PROGRAMS SHOULD NEVER DELAY OR AVOID SEEKING MEDICAL ADVICE OR ATTENTION FROM THEIR REGULAR HEALTH CARE PROVIDER OR TREATING PHYSICIAN OR DOCTOR BECAUSE OF SOMETHING THEY HAVE LEARNED THROUGH THEIR USE OF NAVYA S PRODUCTS, SERVICES, SYSTEMS, PROJECTS, OR PROGRAMS. SHOULD ANY UNEXPECTED MEDICAL EVENT OCCUR WHILE AN INDIVIDUAL OR A PATIENT IS PARTICIPATING IN THE USE OF NAVYA S PRODUCTS, SERVICES, SYSTEMS, PROJECTS, OR PROGRAMS, THE INDIVIDUAL OR THE PATIENT SHOULD IMMEDIATELY CALL THEIR HEALTH CARE PROVIDER OR TREATING PHYSICIAN OR DOCTOR OR LOCAL EMERGENCY ASSISTANCE NUMBER OR IMMEDIATELY VISIT THEIR LOCAL EMERGENCY ROOM. NAVYA AND ITS EMPLOYEES, CONSULTANTS, PARTNERS, AND EXPERTS ARE NOT AND SHALL NOT BE CONSTRUED AS BEING YOUR DOCTORS OR PHYSICIANS OR ONCOLOGISTS OR HEALTHCARE PROVIDERS FOR ANY PURPOSE WHATSOEVER. Navya Inc does not diagnose, treat, give orders, or have the ultimate authority over the care of any individuals. Page 7