Nadofaragene re-induction in NMIBC: Bogdana Schmidt, MD, MPH, on patient selection and outcomes

In this video regarding a recent study evaluating re-induction with nadofaragene firadenovec (Adstiladrin) for BCG-unresponsive non–muscle invasive bladder cancer, Bogdana Schmidt, MD, MPH, an assistant professor of urology at the University of Utah Huntsman Cancer Institute in Salt Lake City, emphasizes that patient preference often drives consideration of this strategy.

Many of her patients travel long distances to a high-volume referral center, making the every-3-month dosing schedule particularly appealing compared with more intensive regimens or radical cystectomy. When patients request another attempt at nadofaragene, she often views re-induction as reasonable—provided they understand that further treatment decisions may still be necessary if disease persists. She is most cautious, however, in patients with T1 + carcinoma in situ (CIS), a group with very high-risk disease where delaying definitive therapy is more concerning. In contrast, she feels comfortable offering re-induction to those with papillary-only disease or CIS ± small-volume high-grade Ta, who tend to respond better.

Schmidt notes that differences in response rates between disease subtypes largely reflect inherent tumor biology. CIS-containing disease is consistently more aggressive, and the 30% to 40% complete response rates seen with re-induction in this group align with expectations across prior trials and imaging datasets.

With a median follow-up of 15 months, most post–re-induction events have been recurrences rather than progression. Patients tend to recur with the same histologic pattern they initially presented with; no papillary-only patients converted to CIS in her cohort. Only 1 patient progressed to muscle-invasive disease, raising the possibility that undetected aggressive disease may have been present from the start. She stresses the importance of thoroughly evaluating the upper tracts, prostatic urethra, and deeper disease before repeatedly sequencing therapies to avoid undertreating patients with occult advanced cancer.

As newer intravesical agents enter the treatment landscape, Schmidt said she still sees a role for nadofaragene firadenovec and considers re-induction a reasonable option for appropriate patients. Future decisions will balance efficacy, durability, administration schedules, and patient preferences. Although newer agents may show higher 12-month complete response rates, nadofaragene’s favorable dosing and tolerability will remain compelling factors in shared decision-making.