Ravi Chauhan, MD, discusses integrating nadofaragene into clinical practice

In this interview, which took place at the 2025 LUGPA Annual Meeting, Ravi D. Chauhan, MD, FACS, a urologist at the Conrad Pearson Clinic in Memphis, Tennessee, discusses the practical advantages and clinical integration of nadofaragene firadenovec (Adstiladrin), a quarterly intravesical gene therapy for non–muscle invasive bladder cancer (NMIBC). Chauhan highlights that the once-every-3-month dosing schedule significantly improves patient convenience and adherence compared with traditional BCG regimens, which require more frequent visits. Patients appreciate the reduced treatment burden and perceive the infrequent dosing as indicative of a strong therapeutic effect.

Operationally, Chauhan’s practice relies on a team-based approach, involving nurse navigators and advanced practice providers (APPs) who track patient schedules, ensure timely cystoscopic surveillance, and maintain continuity of care. Regular team meetings allow the group to monitor patients on advanced therapies collaboratively.

When choosing between nadofaragene and other treatments such as intravesical chemotherapy or pembrolizumab (Keytruda), Chauhan said he favors intravesical options for their ease of administration, lower toxicity, and patient convenience. He sees systemic immunotherapy as less practical as an initial therapy when a localized, infrequent alternative exists.

Chauhan notes that the NMIBC treatment landscape is evolving rapidly, with ongoing trials and new agents expanding available options. He emphasizes the need for long-term efficacy data to refine treatment sequencing and identify which therapies best suit specific disease subtypes.

He is particularly enthusiastic about nadofaragene’s novel mechanism—an adenoviral vector that transforms bladder cells into “interferon factories,” enabling ongoing local cancer suppression. Looking ahead, Chauhan expects it to hold a major role in NMIBC management. He also underscores the importance of industry support in mitigating financial and logistical barriers, as the high cost of advanced therapies can deter adoption in community practices. Overall, Chauhan views nadofaragene as a powerful, patient-friendly innovation within a rapidly advancing field.

Urology Times: From a practical standpoint, how has the quarterly dosing schedule of nadofaragene affected workflow in your clinic, and do you see logistical or patient adherence advantages?

Chauhan: We've been very glad and excited about the fact that it is a once-every-3-month dosing. Patients seem to think that it is a much more convenient treatment regimen, in fact, after getting loads of BCG once a week for 6 weeks and then once a week for 3 weeks on their maintenance schedule. When they hear that they only have to come in and get a dose every 3 months, they're very excited. They also think that somehow, because it's only every 3 months, it must be a super powerful drug, and they're excited to be on that regimen.

Urology Times: Are there any practical pearls or insights that you have for ensuring smooth administration, especially in the community setting?

Chauhan: In our practice, we have a nurse navigator, along with an APP, who help to manage all of our patients who are on these types of advanced medications we have. I think they use a spreadsheet or what have you, and they make sure that everybody is on time with their cystoscopies for surveillance every 3 months. And then, when we find out that a patient is responding well to a medicine, we make sure that they get on schedule so that nobody falls through the cracks.

Urology Times: You mentioned you have APPs who are working with you in your practice. How have they been incorporated into the delivery and monitoring of nadofaragene firadenovec?

Chauhan: We tend to meet once every few weeks to go over a patient list of who all is getting advanced therapies. We utilize the nursing navigators as well as the APPs to help see the patients, help counsel them, along with whenever I see the patients as well. It's almost like we all work in concert, such that we make sure that we take care of all of the patients who are currently on those therapies.

Urology Times: What patient factors most often influence your choice between nadofaragene firadenevoc or other therapies like intravesical chemotherapy, pembrolizumab, or other options?

Chauhan: Intravenous immunotherapy obviously has an NCCN [National Comprehensive Cancer Network] guideline role for this type of disease space, but I have found that it is much easier to instill an intravesical agent rather than infusing an immunotherapy agent, from both an [adverse event] profile, from a patient convenience standpoint, and a frequency of dosing [standpoint]. So we definitely are not looking to immunotherapy as a first-line therapy once we know that we have a very convenient every-3-month option to put in the bladder.

Urology Times: What is still needed to guide treatment decisions in this space?

Chauhan: Well, I think the data, as they bear out, will help us to know what is the long-term efficacy for all these treatments. Clearly, this space is very active. It's an embarrassment of riches as I keep hearing. We have so many treatment options that we didn't even have 2 years ago. I suspect that as the data mature, we will learn what treatments are more efficacious for certain disease states. And I see that happening with all the clinical trials that I see and the ones that we participate in.

Urology Times: Looking ahead, where do you see nadofaragene firadenovec fitting within the broader treatment landscape for non-muscle invasive bladder cancer?

Chauhan: For me and the patients, it's a very convenient dosing schedule, and it's a very efficacious treatment. The treatment is very novel, using an adenoviral vector mediated immunotherapy, basically converting your bladder into an interferon factory such that it can actively treat bladder cancer long after the dose has been removed. And I suspect that, as the data bear out, this will have a very large space in terms of its usage in clinical practice.

Urology Times: Looking at the field of bladder cancer more broadly, which new agents or ongoing trials excite you the most?

Chauhan: There are a lot of trials currently going on in the BCG-naive space, and I think that's an unmet need in our field. We have a lot of drugs that are available for CIS [carcinoma in situ] BCG-refractory disease. And I think once we can get indications for papillary disease and BCG-naive disease that we will have a whole lot more treatment options. As the studies get done, my hope is that we have many more options for that disease space.

Urology Times: Is there anything you would like to add?

Chauhan: One of the things regarding operationalizing these medicines is that there is a huge cost factor, and I am very glad to see that industry support has been very robust. Regarding support for practices, there is a large fear among practices for adopting these therapies because the price tag is high for a lot of these medicines. But the industry support regarding this has been very good, and there is a lot of backstop, especially with nadofaragene regarding practice support and making sure the practice is made whole if there are any billing problems regarding reimbursement.