3.

REVIEW OF LITERATURE

The immune system is one of our most complex biological systems in the body. Immunology is
one of the most rapidly developing area of medical biotechnology research and has great promises
with regard to the prevention and treatment of a wide range of disorders such as the inflammatory
diseases of skin, gut, respiratory tract, joints and central organs. In addition infectious diseases are
now primarily considered immunological disorders while neoplastic diseases, organ
transplantation and several autoimmune diseases may involve in an immunosuppressive state.

In recent years, it has become increasingly apparent that free radicals play a critical role in a variety
of normal regulatory pathways. Yet, dysregulation may play an important role in inflammation.
Thus, oxidant-antioxidant balance is critical for immune cell function because it maintains cell
membrane integrity and functionality, cellular proteins, and nucleic acids. Moreover, this balance
is important in controlling signal transduction and gene expression. Immune cells are particularly
sensitive to oxidative stress because of the high percent of polyunsaturated fatty acids in their
plasma membranes and a higher production of reactive oxygen species (ROS), which is part of
their normal function. It seems appropriate that immune system cells generally have higher
concentrations of antioxidant micronutrients than other cells (Joseph A. Knight, 2000). In an early
study, (Belding et al., 1970) recognized that oxidants are involved in viral inactivation. Subsequent
reports have shown that ROS and antioxidant micronutrients have significant roles in numerous
viral infections, including measles, influenza, human immunodeficiency virus (HIV), and virus-
related hepatitis (Peterhans E, 1997).

3.1 Immune system:

Immune system is a remarkably sophisticated defense system within vertebrates, to protect them
from invading agents. It generates multiple cells and molecules capable of recognizing and
eliminating limitless varieties of foreign and undesirable agents. The human immune response is
a highly complex and extraordinarily sophisticated system involving both innate and adaptive
mechanisms. It is a network of cells and organs that work together to defend the body against
attacks by foreign invaders. The degeneration and atrophy of immune organs will influence the
normal functions of the whole immune system (Yu F. et al, 2007). Immunity is a homeostatic
process, a series of delicately balanced complex, multicellular and physiologic mechanisms that
allow an individual to distinguish foreign material from “self” and neutralize and/or eliminate the
foreign matter (Kaminski et al., 2008). Immunoregulation is a complex balance between regulatory
and effector cells and any imbalance in the immunological mechanism can lead to pathogenesis.
The immune system is involved in the etiology as well as pathophysiologic mechanism of many
diseases. The immune system is primarily concerned with resistance against foreign invaders and
protection against neoplastic cells. Leukocytes (B- and T-lymphocytes, natural killer (NK) cells,
macrophages and granulocytes) are the major cellular players involved. Immune cells in adult
mammals are produced primarily by the bone marrow, which serves both hematopoetic and
immunopoetic functions. This organ is of paramount importance, as it is the only lymphoid tissue
capable of providing the complete restoration of primary lymphoid tissue (spleen, thymus, lymph
nodes and liver), and therefore can alone prevent adult mammal death following lethal irradiation.
In most mammalian species, the bone marrow itself acts also as a primary and secondary lymphoid
organ, regulating the production, differentiation, and maturation of lymphocytes (Elgert, 1994;
Tizard, 1997). The immune system is composed of two major subdivisions, the innate or non-
specific immune system and the adaptive or specific immune system:

Fig 1. Cells of the immune system and their products.

3.1.1 Non-specific immunity:
The innate immune response is the body’s first line of defence against infection; an ubiquitous
non-specific process aimed at regulating numbers of infectious organisms and preventing the first
step in infection, colonization (Basset et al., 2003). An infectious disease process begins with
penetrance of the first defense barriers by foreign invaders. The mammalian physical and chemical
barriers include the skin, mucous membranes, saliva, and gastrointestinal and other secretions,
consisting of symbiotic bacteria or lytic enzymes to destroy or halt the progress of the pathogen
(Elgert, 1994; Tizard, 1997). After invader penetration, mammals exhibit similar first-line defense
immunity, which is non-specific in nature and therefore does not involve prior pathogen
sensitization. These reactions primarily involve myeloid and mononuclear phagocytes, which
respond to chemotactic factors (produced by the affected tissue cells or the invader itself) and
destroy any foreign particles or microorganisms quickly and indiscriminately via phagocytosis
(Colloquium on Clinical Immunology, 1982). The myeloid cells, also called granulocytes or
polymorphonuclear leukocytes, are generally the first defenders to arrive at the invasion site. They
perform phagocytosis quickly, but are short-lived and therefore cannot mount a sustained reaction.
Myeloid cells possess irregularly shaped, lobulated nuclei, and fall into three types depending on
their ability to take up certain dyes: basophils (acidic), eosinophils (basic), and neutrophils (neither
acidic nor basic). In contrast to myeloid cells, they are relatively long-lived and therefore capable
of sustained, repeated phagocytic activity. Additional important functions include the processing
and presentation of antigen in preparation for the specific immune responses, amplification and
control of immune responses by the release of soluble interleukin mediators, and removal of dead,
dying and damaged cells important to the healing process (Grey and Chestnut, 1985).Another cell
important to the initial non- specific destruction of invaders are natural killer (NK) cells, which
are among the 15% of lymphocytes that do not contain either the B- or T-cell markers. They are
large, granular, non-adherent and non-phagocytic lymphocytes, which react through chemotactic
factors to destroy foreign cells through killing mechanisms similar to specific T-cell cytotoxicity,
and are also very important to the elimination of circulating and solid neoplastic cells (Grey and
Chestnut, 1985).

3.1.2 Specific immunity: The adaptive immune system, also known as the acquired immune
system or, as the specific immune system, is a subsystem of the overall immune system that is
composed of highly specialized, systemic cells and processes that eliminate or prevent
pathogen growth. Regardless of cell-type, the antigen is broken-down in various compartments,
and depending on the processing and physiochemical nature of the antigen, select short (8-10
amino acid in length) peptide sequences of proteinaceous antigen, called epitopes, are associated
with molecules called major histocompatibility class I or II complexes (MHC-I or MHC-II;
(Reiness, 2004)) for cell-surface presentation of the epitope to T-cells. Once a foreign entity is
recognized by the first-line defenders, a specific immune response is initiated against the epitopes
(cell-surface markers/receptors) of the invader by an interaction with major histocompatibility
complexes (MHC I or II), interleukins (IL), and either T-helper cells (Th) or cytotoxic T-cells (Tc)
(Elgert, 1994; Tizard, 1997).

The macrophages can also retain a small peptide sequence of the invader to display on their cell
surface. Therefore macrophages (and also B-cells, dendritic/langerhans cells, and other IL-1
producing cells) are denoted as antigen presenting cells (APCs), capable of recognizing and
presenting antigen to specific immune cells. Following phagoytosis of extracellular antigen, small
peptide fragments of the invader (10-20 amino acids) are produced, which have high affinity for
the MHC II transport protein within the cell. Transport of the antigen-MHC II complex to the
surface of the cell allows the Th cell to recognize it as foreign, and a specific antibody- mediated
response could be initiated. Th cells cannot recognize antigen unless it is bound by MHC II, which
is termed as MHC restriction. Alternatively, some APCs are poorly phagocytic, but can bind
antigen to cell-surface MHC II, and present to Th cells in this manner (Grey and Chestnut, 1985).
If the antigen is endogenous (derived from inside the cell, such as viral proteins), the protein is
fragmented by the cell, but now carries high affinity for MHC I. Transport to the cell surface now
allows Tc cells to recognize the foreigner, and a certain cell-mediated response ensues (Unanue,
1984).

3.1.2 (i) Cell mediated immunity:

Cell-mediated immunity (CMI) was a term used originally to describe reactions which were
mediated by lymphocytes and phagocytes rather than antibody-localized reactions usually
involving intracellular pathogens, cancer or tumor cells, or foreign grafts. However, it is now used
in a more general sense for any response against organisms, tumors, or foreign antigen in which
antibody plays a subordinate role, including Th-cell dependent and independent reactions,
macrophage activation by lymphokines, natural killer cell cytotoxicity, and granuloma formation,
as well as cell-mediated cytotoxicity, both antibody independent and dependent (the latter termed
ADCC, or antibody dependent cell-mediated cytotoxicity). Antigens and organisms that are inside
cells cannot be seen by circulating antibody and complement, therefore these CMI responses are
necessary to maintain normal homeostasis of the individual. Cell-mediated cytotoxicity is carried
out primarily by T-cells, which are indistinguishable from B-cells morphologically, however they
can be defined on the basis of surface receptors or proteins, their ontogeny (where they develop),
enzymes produced, and response to molecules (mitogens) that provoke cell division. T-cells
mature primarily in the thymus (Townsend and Bodmer, 1989).
Th1 cells are T lymphocytes that belong to the CD4+ subset. They participate in cell-mediated
immunity, which is essential for controlling intracellular pathogens like viruses and certain
bacteria. Antigen presentation by dendritic cells (DCs) to the T cell receptors (TCRs) of premature
CD4+ Th cells, coupled with secretion of IL-12, indicates Th1 cell production. IL-12 stimulates
Th1 cells to secret their own lymphokines, including tumor-necrosis factor-beta (TNF-β) and
interferon gamma (INF-γ). These cytokines stimulate macrophages and the recruitment of
leukocytes to the site, resulting in inflammation. Th1 cell action together with NK cell and
macrophage activity maintain a complex signaling cascade whose vital goal is the effective
destruction of target cells, especially virally infected or stressed host cells. In order to reinforce the
Th1 immune response, the Th2 responses are suppressed in two ways. First, IFN-γ and IL-12,
secreted by Th1 cells, inhibit the formation of Th2 cells. Second, IFN- γ inhibits class-switching
in B cells.

3.1.2 (ii) Humoral immunity:

Humoral immunity targets exogenous foreign material via antibody binding, and is mediated
primarily by the B- lymphocytes-small round cells with a single large, round nucleus and very
little cytoplasm. These lymphocytes make up only about 5% of the total lymphocyte population
and are relatively short-lived, but are nonetheless very important. Most originate from the bone
marrow and mature before migrating to the other primary and secondary lymphoid tissues (Elgert,
1994; Tizard, 1997). All lymphocytes carry antigenic surface molecules/receptors known as cluster
of differentiation (CD) antigens, which denote function and identification. There are over 80 CD
antigens described to date in mammals, and most are homologous across mammalian species. As
well, most B-cells carry both MHC class I and II antigens, various interleukin receptors, and all
B-cells carry a distinct B-cell receptor (BCR-capable of binding either APC processed or free
antigen) and a complement (CO) receptor for recognition and response to foreign antigen (Elgert,
1994; Tizard, 1997).
B-cells initiate body protection after recognition of antigen through the B-cell receptor with
appropriate Th help. Remarkably, there is enough variability among the population of lymphocyte
specific receptors that nearly any type of foreign invader can be recognized by the immune system.
When the antigen is presented in conjunction with an MHC II molecule, a CD4+ Th cell can
recognize it and bind. Strong binding alone, however, is not sufficient to promote an immune
response, and indeed, may lead to tolerance to the antigen. Therefore, IL-1, a very important co-
stimulator molecule released by APCs is necessary. Under these correct circumstances, the Th
cells will then secrete IL-2 and IL-4, which will immediately promote the B-cells to begin a
proliferation or clonal selection process, greatly elevating the proportion of B- cells specific for
the particular antigen. These cells in turn differentiate into plasma cells (mature B-cells capable of
producing large quantities of antibody proteins) or memory cells (B-cells which can very quickly
proliferate and produce an even greater amount of antibody upon a subsequent exposure to the
same antigen) (Colloquium on Clinical Immunology, 1982).

In contrast, Th2-type immunity involves the neutralization and elimination of extracellular

pathogens and toxins by antibody-mediated processes. A Th2-type antibody response is mediated
by cytokines like IL-2, IL-4, IL-5, IL-9, IL-10, IL-13 and TGF-β which provide the second signal
to induce antigen-primed B-cells (McHeyzer-Williams, 2005) to produce a range of antibodies
types and subclasses like IgG1, IgA, IgM, and IgE (Finkelman et al., 1990). Antibodies (Ab) are
proteins known as immunoglobulins, produced by immature and mature B-cells (plasma cells) in
response to each recognized exogenous foreign invader. In mammals there are five main isotypes
of immunoglobulin: IgM (mostly stimulated by the primary response), IgG (for the memory
response), IgA (in secretory fluids), IgE (cell-associated, often implicated in allergic reactions),
and IgD (on membranes of B-lymphocytes, possibly important in recognition)
The humoral immune system affords the ability to adequately protect the host from unanticipated
pathogens. This system is made possible through the generation of a plethora of receptors which
can recognize a wide array of antigens. Th2 cells are produced in a manner similar to Th1 cells,
but with different cytokines. Th2 cells provide help for B cells and are essential for antibody-
mediated immunity, which is needed to control extracellular pathogens. B cells have specialized
receptors which bind and engulf soluble antigens through receptor-mediated endocytosis. The
antigen is digested into fragments which are then displayed at the cell surface within a class II
histocompatibility molecule. Th2 cells with complementary TCRs bind the B cell and secrete
lymphokines that induce B cell differentiation into a clone of plasma cells that secrete identical
antibodies. These antibodies recognize and bind to an epitome on an antigen and trigger a
constructive response to the antigen. Th2 cells secrete four major lymphokines. IL-4 stimulates
class-switching in B cells to promote synthesis of IgE antibodies and promotes premature Th cells
to enter the Th2 pathway while simultaneously inhibiting the Th1 differentiation pathway. IL-5
recruits and activates eosinophils at the site of action. IL-10 inhibits IL-12 production by DCs
therefore adding another inhibitory mechanism to the Th1 differentiation pathway. Like IL-4, IL-
13 also promotes the synthesis of IgE antibodies (Vojdani A. and Erde J, 2006).

3.2 Role of Ocimum spp. in immunomodulation:

Plant extracts are potentially curative. Some of the extracts can boost the humoral (Rehman et
al., 1999) and cell mediated immunity (Upadhyay et al., 1992) against virsuses (Calixto et al., 1998),
bacteria (Boyanova and Neshev, 1999), fungi (Ali et al., 1999), protozoa (Sharma et al., 1998) and
cancer (Wong et al., 1994). Some of the plants known to have an immunomodulatory activity like
Piper betle, Allium sativum, Aloe vera, Withania somnifera, Azadiracta indica, Tinospora cordifolia,
Zingiber officinalis etc.
Tulsi is one of the effective immunomodulator. Essential oil of leaf and fixed oil of O.
sanctum seed have been shown to modulate humoral and cell mediated immune responses in non-
stressed and stressed animal (Mediratta et al., 1988; Mediratta et al., 2000). Ocimum gratissimum
aqueous leaves extract have good analgesic or antinociceptive activity (Vikram et al., 2011).
Immunotherapeutic potential of O. sanctum aqueous leaf extract in bovine sub-clinical mastitis
after intra-mammary infusion of aqueous extract showed that it reduced the total bacterial count
and increased neutrophil and lymphocyte counts with enhanced phagocytic activity and phagocytic
index (Mukherjee et al., 2005). It is investigated that the immunoregulatory profile of methanolic
extract and an aqueous suspension of O. sanctum L. leaves to antigenic challenge of Salmonella
typhosa and sheep erythrocytes in albino rats indicating an immunostimulation of humoral
immunogenic response as represented by an increase in antibody titre in both widal and sheep
erythrocyte agglutination tests as well as cellular immunologic response represented by E-rosette
formation and lymphocytosis (Godhwani et al., 1988).The aqueous extract of O. sanctum at the
oral doses of 100, 200 mg/kg/day in rats enhances the production of RBC, WBC, and haemoglobin
and also enhanced the production of antibodies without affecting the biochemical parameters (Jeba
et al., 2011).

Many cancer vaccines, particularly in combination with immune adjuvants, elicit strong
cellular immune responses leading to the production of Th1 type cytokines (Dalgleish, 2000). The
ethanolic, ethyl acetate, methanolic and chloroform extracts of O. sanctum have anti-obesity potential
(Audipudi et al., 2013). A steam distilled O. sanctum leaf extract has been shown to enhance anti-
SRBCs and IgE antibody titre and to reduce antigen-induced histamine released from peritoneal mast
cells (Mediratta et al., 1988). O. sanctum produced a significant increase in anti-SRBCs antibody titre
and a decrease in percentage histamine released from the peritoneal mast cells of sensitized rats
(humoral immune responses), footpad thickness and percentage leucocyte migration inhibition (cell-
mediated immune responses). The leaf extract of O. sanctum and Argemone mexiana plants in chicken
model enhanced the antibody level and acted as a humoral immunostimulant and T cell suppressive
agent (Varshney et al., 2013). Tulsi has been found to decrease the incidence of benzopyrine-induced
neoplasia and 3-methyl di-methyl amino azobenzene, induced hematomas in experimental animals
(Aruna et al., 1990). Topical treatment with the ethanolic Tulsi leaf extract has been found to produce
significant reduction in the values of tumor incidence (Paplliomas) in the skin of albino mice (Prashar
et al., 1994).
Methanol and aqueous extract of O. basilicum showed 80 and 83% of lymphocyte
proliferation, respectively and it was shown that lymphocyte count was gradually increased due to the
presence flavonoids and terpenoids (Flores et al., 2008). The aqueous extract of O. basilicum
stimulates the antibody production and also enhances the production of RBC and haemoglobin (Jeba
et al., 2011) in rat. O. basilicum extract could be used to treat Th1-dependent inflammatory processes
and autoimmune diseases as well as Th2-dependent allergic disorders. It has been shown that targeted
disruption of the interleukin-10 gene (Rennick et al., 1997) or TGF-β gene (Shull et al., 1992) resulted
in multifocal inflammation in animal studies indicating that both cytokines possesses strong
immunosuppressive effects which may partially explain the growth modulating effect of O. basilicum
extract and a selected number of its constituents has been shown to be capable of downregulating Th1
and Th2 as well as regulatory T derived cytokines via the ERK2 signal pathway in human (Tsai et al.,
2011) and PBMC proliferation by O. basilicum extract was shown to be used for treating infections
(Chiang et al., 2005) and inflammatory diseases (Yasukawa et al., 1993). Aqueous and ethanolic leaf
extracts of O. basilicum triggers both specific and non-specific responses indicated by a significant
increase in the production of circulating antibody titer in response to sheep red blood cells (SRBCs),
potentiated the DTH reaction by facilitating the footpad thickness response to SRBCs in sensitized
mice and also evoked a significant increase in percentage neutrophil adhesion to nylon fibres and
phagocytic activity (Dashputre and Naikwade, 2010).

3.3 Ocimum spp. with antioxidant properties:

A good antioxidant complex supplement actually has advantages over diet sources in that the
complex has many different specific types of antioxidants which seek out and destroy free radicals at
many various cellular sites. The process by which different antioxidants disperse through the
bloodstream to protect the cells at different sites is referred to in science as "antioxidant synergy"
(Hamid et al., 2010). When a specific antioxidant meets a free radical in the bloodstream at its
appropriate activity site, it naturally combines with it and coverts the free radical to harmless water
and oxygen. As a result, as antioxidant increases due to the supplementation of higher amounts of a
greater variety of antioxidants, cellular damage lessens and performance and health improves. In fact,
aside from the numerous scientifically compelling studies addressing the varied health benefits of
antioxidant supplementation, there have been studies completed, demonstrating a dramatic decrease
in injuries in athletic training with the simple addition of a good antioxidant complex supplement
(Melvin H. Williams, 2004).
The brain is uniquely vulnerable to oxidative injury, due to its high metabolic rate and elevated
levels of polyunsaturated lipids, the target of lipid peroxidation. Consequently, antioxidants are
commonly used as medications to treat various forms of brain injury. Antioxidants are also being
investigated as possible treatments for neurodegenerative diseases such as Alzheimer's disease,
Parkinson's disease, and amyotrophic lateral sclerosis and as a way to prevent noise induced hearing
loss (Matteo and Esposito, 2003). Abnormal high levels, oxidative damage to the cells occurs leading
to several pathological conditions, rheumatoid arthritis, hemorrhagic shock, cardiovascular system
disorder, cystic fibrosis, metabolic disorder, gastrointestinal, ulcerogenesis and acquired
immunodeficiency (Hamid et al., 2010).
Tulsi leaves are a potential source of natural antioxidant that could have great importance
as therapeutic agents in preventing or slowing the progress of ageing and age associated oxidative
stress related degenerative diseases. The phenolic compounds, viz., cirsilineol, cirsimaritin,
isothymusin, apigenin and rosmarinic acid, and appreciable quantities of eugenol (a major
component of the volatile oil) from O. sanctum extract of fresh leaves and stems possessed good
antioxidant activity (Nair et al., 1982). The antioxidant properties of flavonoids and their relation
to membrane protection have been observed (Saija et al., 1995). Tulsi helps in protection from
radiation poisoning (Devi et al., 1999) and cataracts (Sharma et al., 1998). The antioxidant
capacity of chloroform extracts of O. sanctum is due to the presence of phenolic compounds to a
great extent and indicates that phenolic compounds, likely to contribute to the free radical
scavenging activity (). Similarly, aqueous extract of O. gratissimum leaf could reduce oxidative
and toxicant activity and enhance specific activities of hepatic antioxidant enzymes in rats
(Ighodaro and O. A. Ebuehi, 2009).

3.4 Other properties of Ocimum spp.

The fixed oil of O. sanctum has antihyperlipidemic and cardioprotective effects in rats fed a
high fat diet (Suanarunsawat et al., 2010). O. sanctum has been shown to possess beneficial effects of
wound healing (Mediratta et al., 1988; shetty et al., 2008; Mediratta et al., 2002). Tulsi reduces blood
glucose levels in type 2 diabetics when combined with hypoglycemic drugs (Rai et al., 1997) and
also showed significant reduction in total cholesterol levels and another study showed its beneficial
effect on blood glucose levels is due to its antioxidant properties (Sethi et al., 2004). In another report,
the leaf extract of Tulsi has hypoglycaemic effect in normal and diabetic rats (Chattopadhaya, 1993).
Yamasaki et al., 1998 showed that sweet basil aqueous extracts have an anti-HIV action and have an
action on the cardiovascular system. Ethanolic extract of leaves of O. basilicum showed wound
healing activity through topical route on excision wound model at a faster rate than standard topical
application (Solanki et al., 2012).
Tulsi have been shown to possess anti-stress activity (Bhargava and Singh, 1981; Dadekar et
al., 1988), anoxia tolerance (Singh et al., 1989), adaptogenic effects in induced narcosis in rats,
(Ahumada et al., 1991). Trivedi et al., 1995 carried a clinical evaluation of the leaf powder for
laryngopharyngitis, bronchial asthma and in stress-related hypertension. It was found to be a highly
efficacious immunomodulator in humans. Psychotropic effects of an essential oil and water extract
have been shown on the behaviour of rats under acute emotional stress and on the status of the
lymphoid organs (thymus, adrenal glands and spleen) (Kozlovskaya, 1996).
Sadekar et al., 1998 carried out research on the immunostimulatory effect of dry leaf powder
on humoral response in poultry, naturally infected with infectious bursal disease, IBD virus. Sweet
basil (O. basilicum) has been reported to be cytotoxic to human cancer cells (Manosroi et al., 2006).
It has been shown that the active phytochemicals namely urosolic acid and oleanolic acid present in
Tulsi plants have potential to exhibit anticancer property (Singh et al., 2010).

3.5 Clinical relevance:

Herbs or plants which have been widely used in ethnopharmacology are the great source of
immunomodulator. Immunomodulator especially immunostimulator carries number of potential
benefit in maintaining strong immune system especially for the cancer patient who have been
associated with poor immunity while undergoing chemotherapy (Abdulamir et al., 2008). From
ancient times, medical treatment in India has relieved to a large extent on the use of plants. Combining
immunotherapy with conventional treatment such as chemotherapy or radiotherapy also needs further
exploration. The mechanisms of potential synergy include increased presentation of tumour antigens
released from dying cancer cells and induction of a T-cell infiltrate due to inflammation (Barker and
Postov, 2013).

Selecting an appropriate immune cells and specific immune organ as a target for
immunomodulation research allows the understanding of the interaction of those particular substances
with the specific immune cells. The ideal immunomodulator should be able to transform the immune
system from a state of tolerance of a patient’s cancer to one that seeks out and destroys malignant
cells without any added toxicity to normal tissue. Given the complexity of the immune response and
the many players involved, this is unlikely to be achieved by a single-pronged attack. There is much
promise in combination of these agents with other treatment modalities, especially as the efficacy
gains seem to be achieved without significantly increased toxicity. Furthermore, they may potentially
be used against a much broader range of malignancies than the presently available monoclonal
antibodies and cancer vaccines.
 Several immunomodulators are being tested in the clinic, but further developmental work is
necessary to identify the best method to integrate these agents into the existing treatment regimens.
For example, most, if not all, trials of immunotherapeutic approaches are conducted against advanced
tumors. These patients are likely to have some degree of immunosuppression from the cancer itself
and as a result of previous treatment. Incorporating immunomodulators into the adjuvant setting might
be more effective (Barker and Postov, 2013).

Antioxidants have been known to play an important role in alleviating the deleterious
effects induced by free radicals by blocking the initiation or propagation of oxidizing chain
reactions. Both synthetic and natural antioxidants have tremendous potency to prevent free radical
formation, however, the former have often been found to be unsafe or toxic in the long term . Thus,
the global interest has currently shifted towards the use of natural antioxidants, mostly present in
herbs for health benefits interest has currently shifted towards the use of natural antioxidants,
mostly present in herbs for health benefits.