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Volume 17, Issue 2 (2025)
Iran J War Public Health 2025, 17(2): 191-196 |
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Ethics code: INTI-FHLS-03-01-2021
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Received: 2025/03/18 | Accepted: 2025/06/18 | Published: 2025/06/28
Received: 2025/03/18 | Accepted: 2025/06/18 | Published: 2025/06/28
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Alhnon F, Hassan F. Impact of Chemotherapy on Antioxidant Vitamins in Lymphoid Cancer. Iran J War Public Health 2025; 17 (2) :191-196
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F.J.H. Alhnon *1, F.A. Hassan1
1- Department of Chemistry, College of Science, Al-Nahrain University, Baghdad, Iraq
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Introduction
Lymphoid cancers represent a major subset of hematologic cancers, with an increasing incidence worldwide, particularly in Iraq [1]. Chemotherapy continues to play a primary role in the treatment of lymphoid diseases; nevertheless, its therapeutic effect is often accompanied by systemic oxidative stress as an unintended consequence. This occurs as a result of the excessive production of reactive oxygen species (ROS), which are intended to destroy cancerous cells but inadvertently damage healthy, rapidly dividing cells, such as those in the bone marrow and the gastrointestinal tract (GIT). This dual action contributes to many of the treatment’s adverse effects and complicates patient recovery [2].
The oxidative stress induced by chemotherapy contributes significantly to the development of fatigue, mucositis, and metabolic disturbances, thereby affecting treatment tolerability and overall patient outcomes [3]. To maintain redox homeostasis, the human body employs a comprehensive antioxidant defense system comprising both non-enzymatic and enzymatic components. Enzymatic scavengers, such as catalase, glutathione peroxidase, and superoxide dismutase, play a pivotal role in counterbalancing ROS. Concurrently, non-enzymatic protectants, including glutathione, coenzyme Q10, and both vitamins E and C, significantly contribute to mitigating oxidative stress and preserving cellular integrity [4]. The impact of chemotherapy on these non-enzymatic antioxidants, particularly in the context of lymphoid cancers, remains an important but underexplored area, especially in Middle Eastern populations. Vitamin D plays a key role in regulating immune responses, cellular proliferation, and apoptosis—mechanisms that are often dysregulated in cancers [5]. Deficiency in 25(OH)D has been associated with poorer prognosis in both Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL). Patients with widespread peripheral T-cell lymphoma and large B-cell lymphoma who had low vitamin D levels exhibited notably minimal progression-free survival (PFS) and overall survival (OS) rates [6].
Similar findings have been reported in HL, where vitamin D deficiency at diagnosis was linked to inferior treatment response and survival outcomes [7]. Vitamins E and C are essential dietary antioxidants that function synergistically to neutralize ROS. Vitamin E, being fat-soluble, integrates into cell membranes and protects them from lipid peroxidation by scavenging lipid peroxyl radicals. Water-soluble vitamin C not only directly neutralizes free radicals but also rejuvenates oxidized vitamin E, thereby maintaining its antioxidant capacity [8]. Emerging research indicates that chemotherapy can significantly reduce serum levels of these vitamins, thereby worsening oxidative damage [9]. Recent clinical investigations have shown that integrating elevated-dose intravenous vitamin C with standard chemotherapy protocols may contribute to improved therapeutic outcomes and reduced treatment-related toxicity. Patients receiving this combination have demonstrated enhanced tolerance and extended survival rates, particularly in advanced-stage malignancies [10]. However, others caution against its use during active treatment due to possible interference with oxidative mechanisms required for cytotoxicity [11].
Despite increasing global attention to micronutrient status in oncology, regional data from Iraq and surrounding populations are lacking. This is especially important in contexts of nutritional insufficiency, environmental carcinogens, and unique dietary patterns. To address this gap, our study investigates the serum concentrations of vitamins D, C, and E in lymphoid cancer patients before and after chemotherapy. This research aimed to clarify the biochemical consequences of cytotoxic therapy and provide a foundation for integrative nutritional strategies that may improve outcomes in lymphoma management.
Materials and Methods
This case-control study was performed on 120 participants divided into three groups: 40 healthy controls, 40 newly diagnosed lymphoma patients (pre-treatment), and 40 lymphoma patients receiving chemotherapy. All lymphoma cases were diagnosed clinically and histopathologically at Al-Hussein Hospital, Al-Muthanna, Iraq, from January 2023 to July 2024.
The study objectives were clearly explained to all participants, and their verbal informed consent was obtained prior to enrollment. All data collected were used exclusively for research purposes and were treated with strict confidentiality.
Venous blood (10mL) was collected from all participants. After allowing the samples to clot, the serum was separated by centrifuging for 10 minutes at 3000rpm. Serum concentrations of vitamins D, E, and C were measured using ELISA kits (LSBio, USA, and Elabscience, USA) in accordance with the manufacturers’ instructions (Figure 1).
SPSS 25.0 software was used to analyze the data. The levels of enzymes across the three groups were compared using a one-way ANOVA, and differences among groups were further investigated with Tukey’s post hoc test. A p-value of <0.05 was considered indicative of statistical significance.
Findings
There was a significant reduction in the concentrations of antioxidant vitamins C, E, and D3 in lymphoma patients, both untreated and those receiving chemotherapy, compared to healthy individuals (Table 1).
Table 1. Mean serum concentration of antioxidant vitamins (C, E, and D) in subjects
Vitamin C levels
The untreated group’s mean serum vitamin C levels were considerably lower at 17.30±4.80µmol/L compared to the control group, which had a mean of 37.71±9.10µmol/L. Treated patients showed a partial recovery with a mean of 25.10±9.06µmol/L, but their levels remained lower than those of the healthy group. The differences among all groups were statistically significant (p<0.0001), indicating a partial positive effect of chemotherapy on vitamin C status.
Vitamin E levels
A significant decrease in vitamin E levels was observed in untreated cases, with a mean of 1394.90±205.60µg/dL, compared to the control group, which had a mean of 2540.80±711.50µg/dL. Although patients undergoing chemotherapy showed a slight increase in vitamin E levels at 1873.70±577.40µg/dL compared to untreated patients, their levels remained significantly lower than those recorded in healthy individuals. There were statistically significant differences across all groups (p<0.0001), indicating a partial improvement without a complete return to normal.
Vitamin D3 levels
Vitamin D3 levels were lowest in the untreated group, at 9.48±1.81ng/mL, compared to 23.44±6.17ng/mL in controls. Following treatment, levels rose to 13.70±6.10ng/mL, indicating partial improvement. A highly significant intergroup difference was detected by ANOVA (p=0.0001).
Receiver operating characteristic (ROC)
Vitamin C demonstrated a clear separation in concentrations between groups, as reflected in the ROC curve (Figure 1), indicating its potential as a diagnostic biomarker.
Figure 1. Receiver operating characteristic (ROC) curve of vitamin C among the studied groups.
The ROC curve for vitamin E (Figure 2) similarly displayed meaningful discrimination between patient groups.
Figure 2. Receiver operating characteristic (ROC) curve of vitamin E among the studied groups.
Vitamin D emerged as particularly noteworthy due to its strong ROC performance (Figure 3), suggesting high diagnostic value.
Figure 3. Receiver operating characteristic (ROC) curve of vitamin D among the studied groups.
Discussion
The present study examined serum concentrations of vitamins C, E, and D across different study groups, with a particular emphasis on their diagnostic relevance using ROC curve analysis. The use of standard calibration curves enabled the accurate quantification of each vitamin, providing a robust biochemical foundation for the observed trends.
Prior studies have underscored the antioxidative role of vitamin C and its inverse correlation with inflammatory markers, particularly in populations suffering from chronic illnesses or metabolic disorders [12]. The sensitivity and specificity reported in this study align with existing literature, reinforcing its predictive utility. Given the lipid-soluble nature of vitamin E and its central role in membrane protection and immune modulation, the observed concentration differentials may reflect varying levels of oxidative stress or anomalies in lipid metabolism [13]. The standard curve ensured accuracy in measurement, while the group-wise differences reinforced the hypothesis of vitamin E deficiency in at-risk individuals. This aligns with the growing body of evidence linking vitamin D deficiency with a range of pathological conditions, including immune dysregulation and increased susceptibility to infections [14]. The distribution of vitamin D levels across the study groups indicates potential clinical implications and the need for routine screening, particularly in individuals with limited sun exposure or dietary insufficiencies.
Across all three vitamins, the generated ROC curves not only confirmed statistically significant differences among groups but also highlighted the potential of these micronutrients as non-invasive diagnostic indicators. These findings are particularly relevant in clinical settings where early detection and nutritional intervention can meaningfully alter disease trajectories. However, external confounding factors, such as dietary intake, supplementation, and comorbid conditions, should be considered in future studies. This study underscores the clinical significance of assessing serum levels of vitamins C, E, and D as potential diagnostic biomarkers. The application of ROC curve analysis revealed that all three vitamins exhibited substantial discriminatory power across the study groups, indicating their possible roles in disease identification and progression monitoring. Among them, vitamin D showed the most promising diagnostic performance, consistent with its well-documented involvement in immune and metabolic functions. The integration of standard calibration curves and precise biochemical measurements enhances the validity of these findings, suggesting that routine screening for these vitamins may offer a valuable adjunct to preventive and therapeutic healthcare strategies. Furthermore, the sustained deficiency of antioxidant vitamins even after chemotherapy raises important biological questions. The partial recovery of vitamin levels could reflect decreased tumor oxidative consumption or partial resolution of systemic inflammation. However, continued suboptimal values indicate a lingering imbalance in redox homeostasis.
Chiang et al. [15] report persistent oxidative stress in lymphoma patients despite apparent clinical remission, suggesting deeper molecular disruptions that extend beyond measurable disease. The clinical relevance of this oxidative imbalance is substantial. Long-standing vitamin deficiencies may impair immune surveillance, reduce treatment tolerance, and exacerbate side effects such as fatigue, mucositis, and hematological toxicity. Clinical trials, such as the one conducted by Ping et al. [16], demonstrated that low baseline levels of vitamins C and E are associated with increased chemotherapy-related complications in hematologic malignancies. It is also worth noting that vitamin D3’s diagnostic performance in our study may be related not only to its antioxidant role but also to its immunomodulatory and anti-proliferative functions. In a meta-analysis of over 3,000 cancer patients, Sluyter et al. [17] confirmed that low 25(OH)D concentrations are appreciably linked with poor clinical outcomes across multiple tumor types, including lymphoma. ROC curve analysis further validates these vitamins as potential biomarkers. The area under the curve (AUC) for vitamin D3 was particularly noteworthy, reflecting high sensitivity and specificity in distinguishing diseased from healthy individuals. As established by Li et al. [18], ROC-based evaluation of serum biomarkers is an effective non-invasive diagnostic approach that can support treatment decisions and prognostic evaluation. Our findings also resonate with mechanistic studies examining the role of ROS in mediating both cancer progression and treatment toxicity. A detailed biochemical investigation by Selvaraj et al. [19] highlights how ROS overproduction alters intracellular signaling pathways, depletes antioxidants, and induces genomic instability, all of which may persist despite therapeutic intervention.
Finally, in the context of Middle Eastern populations, where dietary insufficiencies and environmental exposure to carcinogens are more prevalent, the integration of micronutrient assessment into oncology protocols becomes even more critical. Shakir [20] recently emphasized that in Iraqi cancer patients, micronutrient profiling can serve as both a diagnostic adjunct and a therapeutic guide, particularly in settings with limited nutritional support services. Importantly, these insights reinforce the need for nutritional surveillance, especially in vulnerable populations where micronutrient deficiencies are prevalent and clinically impactful. Future studies should aim to validate these results in larger, more diverse cohorts while controlling for confounding parameters such as dietary habits, comorbidities, and supplementation history. A longitudinal approach would further clarify the causal relationships between vitamin levels and disease progression.
Conclusion
Vitamins C, E, and D hold measurable diagnostic potential, and their inclusion in routine biochemical panels contributes meaningfully to early detection and personalized patient care.
Acknowledgments: The authors would like to extend their deepest gratitude to the Department of Chemistry, College of Science, Al-Nahrain University, Baghdad, Iraq, for their continuous academic and laboratory support. Special appreciation is due to Al-Hussein Teaching Hospital, Oncology Center, Al-Muthanna Governorate, Iraq, for their invaluable collaboration in patient recruitment and sample collection. We are sincerely grateful to the patients and their families for their kind participation and cooperation, without whom this research would not have been possible.
Ethical Permissions: Ethical approval for this study was obtained from the Postgraduate Studies Ethical and Scientific Committee, College of Science, Al-Nahrain University, Baghdad, Iraq (Approval Code: 4982; Date: 25/12/2023).
Conflicts of Interests: The authors reported no conflicts of interests.
Authors' Contribution: Alhnon FJH (First Author), Introduction Writer/Methodologist/Main Researcher/Discussion Writer/Statistical Analyst (60%); Hassan FA (Second Author), Introduction Writer/Methodologist/Assistant Researcher/Discussion Writer/Statistical Analyst (40%)
Funding/Support: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Lymphoid cancers represent a major subset of hematologic cancers, with an increasing incidence worldwide, particularly in Iraq [1]. Chemotherapy continues to play a primary role in the treatment of lymphoid diseases; nevertheless, its therapeutic effect is often accompanied by systemic oxidative stress as an unintended consequence. This occurs as a result of the excessive production of reactive oxygen species (ROS), which are intended to destroy cancerous cells but inadvertently damage healthy, rapidly dividing cells, such as those in the bone marrow and the gastrointestinal tract (GIT). This dual action contributes to many of the treatment’s adverse effects and complicates patient recovery [2].
The oxidative stress induced by chemotherapy contributes significantly to the development of fatigue, mucositis, and metabolic disturbances, thereby affecting treatment tolerability and overall patient outcomes [3]. To maintain redox homeostasis, the human body employs a comprehensive antioxidant defense system comprising both non-enzymatic and enzymatic components. Enzymatic scavengers, such as catalase, glutathione peroxidase, and superoxide dismutase, play a pivotal role in counterbalancing ROS. Concurrently, non-enzymatic protectants, including glutathione, coenzyme Q10, and both vitamins E and C, significantly contribute to mitigating oxidative stress and preserving cellular integrity [4]. The impact of chemotherapy on these non-enzymatic antioxidants, particularly in the context of lymphoid cancers, remains an important but underexplored area, especially in Middle Eastern populations. Vitamin D plays a key role in regulating immune responses, cellular proliferation, and apoptosis—mechanisms that are often dysregulated in cancers [5]. Deficiency in 25(OH)D has been associated with poorer prognosis in both Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL). Patients with widespread peripheral T-cell lymphoma and large B-cell lymphoma who had low vitamin D levels exhibited notably minimal progression-free survival (PFS) and overall survival (OS) rates [6].
Similar findings have been reported in HL, where vitamin D deficiency at diagnosis was linked to inferior treatment response and survival outcomes [7]. Vitamins E and C are essential dietary antioxidants that function synergistically to neutralize ROS. Vitamin E, being fat-soluble, integrates into cell membranes and protects them from lipid peroxidation by scavenging lipid peroxyl radicals. Water-soluble vitamin C not only directly neutralizes free radicals but also rejuvenates oxidized vitamin E, thereby maintaining its antioxidant capacity [8]. Emerging research indicates that chemotherapy can significantly reduce serum levels of these vitamins, thereby worsening oxidative damage [9]. Recent clinical investigations have shown that integrating elevated-dose intravenous vitamin C with standard chemotherapy protocols may contribute to improved therapeutic outcomes and reduced treatment-related toxicity. Patients receiving this combination have demonstrated enhanced tolerance and extended survival rates, particularly in advanced-stage malignancies [10]. However, others caution against its use during active treatment due to possible interference with oxidative mechanisms required for cytotoxicity [11].
Despite increasing global attention to micronutrient status in oncology, regional data from Iraq and surrounding populations are lacking. This is especially important in contexts of nutritional insufficiency, environmental carcinogens, and unique dietary patterns. To address this gap, our study investigates the serum concentrations of vitamins D, C, and E in lymphoid cancer patients before and after chemotherapy. This research aimed to clarify the biochemical consequences of cytotoxic therapy and provide a foundation for integrative nutritional strategies that may improve outcomes in lymphoma management.
Materials and Methods
This case-control study was performed on 120 participants divided into three groups: 40 healthy controls, 40 newly diagnosed lymphoma patients (pre-treatment), and 40 lymphoma patients receiving chemotherapy. All lymphoma cases were diagnosed clinically and histopathologically at Al-Hussein Hospital, Al-Muthanna, Iraq, from January 2023 to July 2024.
The study objectives were clearly explained to all participants, and their verbal informed consent was obtained prior to enrollment. All data collected were used exclusively for research purposes and were treated with strict confidentiality.
Venous blood (10mL) was collected from all participants. After allowing the samples to clot, the serum was separated by centrifuging for 10 minutes at 3000rpm. Serum concentrations of vitamins D, E, and C were measured using ELISA kits (LSBio, USA, and Elabscience, USA) in accordance with the manufacturers’ instructions (Figure 1).
SPSS 25.0 software was used to analyze the data. The levels of enzymes across the three groups were compared using a one-way ANOVA, and differences among groups were further investigated with Tukey’s post hoc test. A p-value of <0.05 was considered indicative of statistical significance.
Findings
There was a significant reduction in the concentrations of antioxidant vitamins C, E, and D3 in lymphoma patients, both untreated and those receiving chemotherapy, compared to healthy individuals (Table 1).
Table 1. Mean serum concentration of antioxidant vitamins (C, E, and D) in subjects
Vitamin C levels
The untreated group’s mean serum vitamin C levels were considerably lower at 17.30±4.80µmol/L compared to the control group, which had a mean of 37.71±9.10µmol/L. Treated patients showed a partial recovery with a mean of 25.10±9.06µmol/L, but their levels remained lower than those of the healthy group. The differences among all groups were statistically significant (p<0.0001), indicating a partial positive effect of chemotherapy on vitamin C status.
Vitamin E levels
A significant decrease in vitamin E levels was observed in untreated cases, with a mean of 1394.90±205.60µg/dL, compared to the control group, which had a mean of 2540.80±711.50µg/dL. Although patients undergoing chemotherapy showed a slight increase in vitamin E levels at 1873.70±577.40µg/dL compared to untreated patients, their levels remained significantly lower than those recorded in healthy individuals. There were statistically significant differences across all groups (p<0.0001), indicating a partial improvement without a complete return to normal.
Vitamin D3 levels
Vitamin D3 levels were lowest in the untreated group, at 9.48±1.81ng/mL, compared to 23.44±6.17ng/mL in controls. Following treatment, levels rose to 13.70±6.10ng/mL, indicating partial improvement. A highly significant intergroup difference was detected by ANOVA (p=0.0001).
Receiver operating characteristic (ROC)
Vitamin C demonstrated a clear separation in concentrations between groups, as reflected in the ROC curve (Figure 1), indicating its potential as a diagnostic biomarker.
Figure 1. Receiver operating characteristic (ROC) curve of vitamin C among the studied groups.
The ROC curve for vitamin E (Figure 2) similarly displayed meaningful discrimination between patient groups.
Figure 2. Receiver operating characteristic (ROC) curve of vitamin E among the studied groups.
Vitamin D emerged as particularly noteworthy due to its strong ROC performance (Figure 3), suggesting high diagnostic value.
Figure 3. Receiver operating characteristic (ROC) curve of vitamin D among the studied groups.
Discussion
The present study examined serum concentrations of vitamins C, E, and D across different study groups, with a particular emphasis on their diagnostic relevance using ROC curve analysis. The use of standard calibration curves enabled the accurate quantification of each vitamin, providing a robust biochemical foundation for the observed trends.
Prior studies have underscored the antioxidative role of vitamin C and its inverse correlation with inflammatory markers, particularly in populations suffering from chronic illnesses or metabolic disorders [12]. The sensitivity and specificity reported in this study align with existing literature, reinforcing its predictive utility. Given the lipid-soluble nature of vitamin E and its central role in membrane protection and immune modulation, the observed concentration differentials may reflect varying levels of oxidative stress or anomalies in lipid metabolism [13]. The standard curve ensured accuracy in measurement, while the group-wise differences reinforced the hypothesis of vitamin E deficiency in at-risk individuals. This aligns with the growing body of evidence linking vitamin D deficiency with a range of pathological conditions, including immune dysregulation and increased susceptibility to infections [14]. The distribution of vitamin D levels across the study groups indicates potential clinical implications and the need for routine screening, particularly in individuals with limited sun exposure or dietary insufficiencies.
Across all three vitamins, the generated ROC curves not only confirmed statistically significant differences among groups but also highlighted the potential of these micronutrients as non-invasive diagnostic indicators. These findings are particularly relevant in clinical settings where early detection and nutritional intervention can meaningfully alter disease trajectories. However, external confounding factors, such as dietary intake, supplementation, and comorbid conditions, should be considered in future studies. This study underscores the clinical significance of assessing serum levels of vitamins C, E, and D as potential diagnostic biomarkers. The application of ROC curve analysis revealed that all three vitamins exhibited substantial discriminatory power across the study groups, indicating their possible roles in disease identification and progression monitoring. Among them, vitamin D showed the most promising diagnostic performance, consistent with its well-documented involvement in immune and metabolic functions. The integration of standard calibration curves and precise biochemical measurements enhances the validity of these findings, suggesting that routine screening for these vitamins may offer a valuable adjunct to preventive and therapeutic healthcare strategies. Furthermore, the sustained deficiency of antioxidant vitamins even after chemotherapy raises important biological questions. The partial recovery of vitamin levels could reflect decreased tumor oxidative consumption or partial resolution of systemic inflammation. However, continued suboptimal values indicate a lingering imbalance in redox homeostasis.
Chiang et al. [15] report persistent oxidative stress in lymphoma patients despite apparent clinical remission, suggesting deeper molecular disruptions that extend beyond measurable disease. The clinical relevance of this oxidative imbalance is substantial. Long-standing vitamin deficiencies may impair immune surveillance, reduce treatment tolerance, and exacerbate side effects such as fatigue, mucositis, and hematological toxicity. Clinical trials, such as the one conducted by Ping et al. [16], demonstrated that low baseline levels of vitamins C and E are associated with increased chemotherapy-related complications in hematologic malignancies. It is also worth noting that vitamin D3’s diagnostic performance in our study may be related not only to its antioxidant role but also to its immunomodulatory and anti-proliferative functions. In a meta-analysis of over 3,000 cancer patients, Sluyter et al. [17] confirmed that low 25(OH)D concentrations are appreciably linked with poor clinical outcomes across multiple tumor types, including lymphoma. ROC curve analysis further validates these vitamins as potential biomarkers. The area under the curve (AUC) for vitamin D3 was particularly noteworthy, reflecting high sensitivity and specificity in distinguishing diseased from healthy individuals. As established by Li et al. [18], ROC-based evaluation of serum biomarkers is an effective non-invasive diagnostic approach that can support treatment decisions and prognostic evaluation. Our findings also resonate with mechanistic studies examining the role of ROS in mediating both cancer progression and treatment toxicity. A detailed biochemical investigation by Selvaraj et al. [19] highlights how ROS overproduction alters intracellular signaling pathways, depletes antioxidants, and induces genomic instability, all of which may persist despite therapeutic intervention.
Finally, in the context of Middle Eastern populations, where dietary insufficiencies and environmental exposure to carcinogens are more prevalent, the integration of micronutrient assessment into oncology protocols becomes even more critical. Shakir [20] recently emphasized that in Iraqi cancer patients, micronutrient profiling can serve as both a diagnostic adjunct and a therapeutic guide, particularly in settings with limited nutritional support services. Importantly, these insights reinforce the need for nutritional surveillance, especially in vulnerable populations where micronutrient deficiencies are prevalent and clinically impactful. Future studies should aim to validate these results in larger, more diverse cohorts while controlling for confounding parameters such as dietary habits, comorbidities, and supplementation history. A longitudinal approach would further clarify the causal relationships between vitamin levels and disease progression.
Conclusion
Vitamins C, E, and D hold measurable diagnostic potential, and their inclusion in routine biochemical panels contributes meaningfully to early detection and personalized patient care.
Acknowledgments: The authors would like to extend their deepest gratitude to the Department of Chemistry, College of Science, Al-Nahrain University, Baghdad, Iraq, for their continuous academic and laboratory support. Special appreciation is due to Al-Hussein Teaching Hospital, Oncology Center, Al-Muthanna Governorate, Iraq, for their invaluable collaboration in patient recruitment and sample collection. We are sincerely grateful to the patients and their families for their kind participation and cooperation, without whom this research would not have been possible.
Ethical Permissions: Ethical approval for this study was obtained from the Postgraduate Studies Ethical and Scientific Committee, College of Science, Al-Nahrain University, Baghdad, Iraq (Approval Code: 4982; Date: 25/12/2023).
Conflicts of Interests: The authors reported no conflicts of interests.
Authors' Contribution: Alhnon FJH (First Author), Introduction Writer/Methodologist/Main Researcher/Discussion Writer/Statistical Analyst (60%); Hassan FA (Second Author), Introduction Writer/Methodologist/Assistant Researcher/Discussion Writer/Statistical Analyst (40%)
Funding/Support: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Keywords:
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