key: cord-0015280-aq2v2z09
authors: Huang, Li; Zhao, Yanqing; Xiang, Minhong
title: Knowledge Mapping of Acupuncture for Cancer Pain: A Scientometric Analysis (2000–2019)
date: 2021-02-05
journal: J Pain Res
DOI: 10.2147/jpr.s292657
sha: a0ea95c6674f4071de6d21f2d99e3caddf548a28
doc_id: 15280
cord_uid: aq2v2z09

OBJECTIVE: This study aimed to demonstrate the state of the present situation and trends concerning the global use of acupuncture for cancer pain in the past 20 years. METHODS: Searched the Web of Science database from 2000 to 2019 related to acupuncture for cancer pain, and then used CiteSpace to conduct scientometric analysis to acquire the knowledge mapping. RESULTS: Yearly output has increased year by year, and the growth rate has become faster after 2012. According to the cluster analysis of institutions, authors, cited references, and keywords, 4, 4, 15, and 14 categories were obtained, respectively. The most productive countries, institutions, and authors are the USA, Mem Sloan Kettering Cancer Center, and Mao JJ, whose frequencies are 196, 24, and 17, respectively. However, the most important of them are Australia, Univ. Maryland, and Bao T, owing to their highest centrality, they are 0.90, 0.21, and 0.09 separately. Moreover, cited references that contributed to the most co-citations are Crew KD (2010), however, the most key cited reference is Roscoe JA (2003). Keywords such as acupuncture, pain, breast cancer, palliative care, and quality of life are the most frequently used. But auricular acupuncture is the crucial keyword. In the cluster analysis of institutions, authors, cited references, and keywords, the more convincing research categories are multiple myeloma, placebo effect, neck malignancies, and early breast cancer, with S values of 0.990, 0.991, 0.990, and 0.923, respectively. Therefore, they can be regarded as research hotspots in this field. CONCLUSION: Based on the scientometric analysis in the past 20 years, the knowledge mapping of the country, institution, author, cited reference, and the keyword is gained, which has an important guiding significance for quickly and accurately positioning the trend in this field.

Cancer is the main cause of death that endangers human health in the world. Due to population growth and accelerated aging, the various burdens brought by cancer will gradually increase. 1 Pain is a distressing symptom experienced by more than 70% of cancer patients. 2 According to reports, about 25% of newly diagnosed cancer patients, 33% of patients receiving anti-cancer treatment, and 75% of advanced cancer patients have varying degrees of pain. 3 The vast majority of confirmed patients are from middle-and low-income countries. Among lowincome people, cancer pain patients face additional challenges brought about by infection and poverty. These problems make cancer and cancer pain more complicated. 4 The three-step analgesic ladder adopted by the World Health Organization is effective in the treatment of cancer pain, 5 but analgesics have many adverse reactions, such as nausea and constipation. 6 Therefore, to relieve the adverse drug reactions of cancer pain and the huge economic burden caused by the treatment process, it is urgent to find a suitable alternative treatment plan. Acupuncture is regarded as one of the non-drug therapies to relieve pain and improve function due to its low side effects. This is recognized in the National Comprehensive Cancer Network (NCCN) guideline. 7 Scientometrics is an interdisciplinary science that uses mathematical and statistical methods to quantitatively analyze all knowledge carriers. It provides a reliable method for researchers to deeply understand the study in this field, including the analysis of different databases, such as Web of Science, 8 Pubmed, 9 Scopus, 10 Derwent, 11 etc. Among them, Web of Science is the most common, there is also analysis using different software, for instance: CiteSpace, 12 VOSviewer, 13 Histcite, 14 etc. can be used for scientometric analysis. Using CiteSpace and VOSviewer software as tools to carry out scientometric research occupies the vast majority, and its application scope also covers many fields. In the form of a knowledge map, readers can vividly understand the frontiers, hotspots, and trends of the field, which helps us to clarify the development context of a certain research field. 15 CiteSpace is an information visualization software developed by the Java language. 16 It is used to measure the literature in a specific field to explore the key path and knowledge turning points of the evolution for the subject field. CiteSpace includes co-citation, co-author, and cooccurrence analysis, 17 which is of great benefit to the construction of scientific research cooperation networks and co-occurrence analysis of topics and fields. Then, the three concepts of betweenness centrality, burst detection, and heterogeneous network help identify research frontiers, tag keywords, identifying emerging trends, and sudden changes over time. 18 Therefore, the scientometric analysis of acupuncture for cancer pain through CiteSpace can not only obtain the research trend but also gain knowledge mappings such as cluster views and timeline graphs, which is of great significance for young scholars who will be engaged in research in this field to accurately grasp the research direction.

To date, there has been no comprehensive article of studies on acupuncture for cancer pain using bibliometric methods. Therefore, in this study, to analyze the global status and trend of acupuncture for cancer pain in the past 20 years, the researchers used CiteSpace to analyze the relevant literature in the web of Science Database (SCI-E) from 2000 to 2019, so as to construct the knowledge map of this field.

To prevent the omission of searching the literature, we use "acupuncture" to search for synonyms in the MeSH Database, the subject word database in Pubmed, and then merge the final data. At the same time, search for synonyms of "cancer", mainly including carcinoma, neoplasm, and tumor. Firstly, we input the Web of Science database with English Subject words= "cancer" OR "tumor" OR "carcinoma" OR "neoplasm", and TS= "pain", and TS= "acupuncture" OR "Acupuncture Therapy" OR "Acupuncture, Ear" OR "Acupuncture Points" OR "Acupuncture Analgesia", 19 respectively. Next is Web of Science database settings: literature was retrieved online through the Science Citation Index-Expanded of the Web of Science Core Collection on October 25, 2020, 20 and the language of the literature is not limited. The search range of the database is 2000-2019, it analyses on this basis. After literature retrieval, a total of 1095 records were obtained, and 504 pieces of literature were used for scientometric analysis after CiteSpace removed duplication. The elimination of literature duplication was carried out in the form of CiteSpace software and manual verification. First, CiteSpace software is used to deduplicate literature, secondly, two researchers were required to check before and after literature deduplication. These two researchers separately examined the papers by title, abstract, and full text. The searched Web of Science database comes from the Peking University Library database in China.

CiteSpace software to remove duplicates and kept a unique record, and then analyzed it.

Time slicing (from 2000 to 2019, years per slice: 2), node type (check one at a time, including Author, Institution, Country, Keyword, Cited Reference), selection criteria (TopN, select top 50 levels of most cited or occurred items from each slice), pruning select Pathfinder, and Pruning the merged network. Because the network obtained by keywords and Cited reference is messy, Therefore, the network screening measures of keywords are as follows: years per slice 3; the keyword analysis should also select pruning sliced networks; and the cited reference analysis also choose pruning sliced networks.

The scientometric analysis was executed on all literature of acupuncture for cancer pain, the frequency of which is mainly utilized to observe the core countries/territories, institutions, authors, cited references, and keywords. Centrality is an indicator to measure the importance of nodes in the network, to discover and measure the significance of the literature. The result of clustering analysis is a keyword co-occurrence network. This network can reflect the current and past research hotspots in a certain field. The cluster view shows the distribution of research fields from different angles. Based on the network structure and the clarity of clustering, CiteSpace provides two indicators: the module value (referred to as Q value) and the silhouette value (referred to as S value), as the basis for us to judge the effect of map drawing, the silhouette value is the average that the contour values of each sample point. Generally speaking, the Q value is generally in the interval [0,1), and Q>0.3 means that the divided community structure is significant; when the S value is 0.7, the clustering is highly efficient and convincing, if it is 0.5 above, clustering is generally considered reasonable. 22 The interpretation of cluster analysis results mainly includes Cluster ID, Mean Year, Size, Silhouette, Label (LLR), and Label (MI). Cluster ID is the number after clustering, and Size represents the number of members contained in the cluster. The larger the Size, the smaller the number. Mean Year represents the average year of the literature in the cluster, which can be used to judge the distance of the cited literature in the cluster. The larger the log-likelihood ratio (LLR), the more representative of the cluster category; mutual information (MI) is mainly used to represent the relationship between terms and categories in text mining, and it does not consider the frequency of feature words. The timeline view mainly shows solicitude for delineating the relationship between clustering results and focuses on the historical span of documents in a clustering result.

In Figure 1 , we found an interesting phenomenon. 1) 2001-2012: the average annual total number of publications on acupuncture for cancer pain was 14.75, which was preserved at the same level without any major fluctuations, indicating that acupuncture for cancer pain during this period is developing stably, which can be considered as a stable period. 2) 2013-2016: at this stage, the average annual total number of publications on acupuncture for cancer pain attained 35.25, compared with the previous period, the growth rate is obvious. 3) 2017-2019: in this period, the average annual total number of publications on acupuncture for cancer pain reached 58.67, compared with the previous two periods, the total number of publications in this period has grown faster. Hence, this period can be named the period of rapid development. Through the comparison of the three, it is found that although the scientific research output of acupuncture for cancer pain has some small fluctuations, the overall development trend is increasing year by year. Network of countries/territories on acupuncture for cancer pain. The purple node in the middle of the annual ring means the influence and the significance of a country/territory. The larger the node and the more purple it exhibits, the greater is the importance of the country/territory. acupuncture originated in China, but the difference is that Chinese scientific institutions are not as important as South Korea in this respect. From the perspective of institutional analysis, the vast majority of institutions are from developed countries, indicating that developed countries are still the world leader in acupuncture for cancer pain, and their cooperation with developing countries is not close. Therefore, developing countries/territories should strengthen cooperation with developed countries/territories and learn from their advanced technologies to promote the development of acupuncture for cancer pain.

Relying on the cluster analysis of institutions, researchers can find the same research category that different institutions are engaged in. This point is mainly based on the cluster view Figure 3A and Table 3 . When the cluster view cannot judge which institutions focus on the same research in detail, it will utilize the cluster timeline view Figure 3B to analyze. The whole modularity Q= 0.8429 > 0.3, which indicates that the results of the divided community structure is significant. Four categories were obtained by cluster analysis, which were #0 nationwide population-based study (Silhouette=0.975> 0.7, Contains 13 institutions), #1 publication trend (Silhouette=0.972>0.7, Contains 12 institutions), #2 physical symptom (Silhouette=0.796>0.7, Contains 9 institutions), and #4 breast cancer patient (Silhouette=0.956>0.7, Contains 6 institutions). The locating similar studies between institutions and discovering potential cooperation relationships between them. However, the cooperation between institutions is mainly based on institutions in developed countries, and the cooperation between international institutions is also mainly in developed countries. Among them, the institutional cooperation between developing countries and developed countries represented by China is still less, which is the deficiency of this research.

A cluster map ( Figure 4A , Modularity Q = 0.8861, Silhouette = 0.5277) with 121 nodes and 169 links of authors was emerged by CiteSpace, along with a timeline view ( Figure 4B ). The distribution of the main scholars engaged in acupuncture for cancer pain is shown in Table  4 . Among them, the author with the most published outputs is Mao JJ (17), followed by Ernst E (9), Johnson MI (6), Cassileth BR (6), and Cohen L (6), but from the perspective of centrality, the highest is Bao T (centrality=0.09), followed by Mao JJ (0.08), Greenlee H (0.07), Cohen L (0.05) and Piulson L (0.04), therefore, they are considered to be the most important researcher in the Author's network relationship. Then through the cluster analysis, the researcher can quickly locate the same research content and the relationship between different scholars. The results of cluster analysis are shown in Table 5 . The modularity Q= 0.8861>0.3, which indicates supratentorial craniotomy (Silhouette=0.842>0.7, Contains 5 authors). The silhouette of all the clustering results was greater than 0.7, it points out that all clustering results are credible. Then the following categories are the specific analysis of the same category of the authors. 1) Bao T, Greenlee H, Piulson L, Vertosick E, Deng G and other authors' research on acupuncture for cancer pain can be classified into the same category, namely: phase iia trial (#0). DengG 23 randomly divided 162 cancer patients undergoing thoracotomy into an acupuncture group and a control group. However, the results showed that this acupuncture treatment did not reduce the pain of cancer patients after thoracotomy or reduce the use of painkillers. This provides a research method worth learning for acupuncture treatment of postoperative pain after cancer. Oh B 24 randomly divided 32 patients with early breast cancer joint pain into an acupuncture group and a sham acupuncture group. The results of the study showed that acupuncture is feasible and safe for the treatment of breast cancer artificial joint pain. However, due to the lack of clinical samples, it still needs large sample clinical studies to validate these results. These results are very important for the development of evidence-based guidelines on the rational use of acupuncture, so it is possible to safely and effectively integrate acupuncture with traditional medicine in the healthcare system, and Bao T's research 25 Through mediating analysis, Meghani SH 31 studies the possibility of African American patients with cancer pain to accept analgesics containing toxic metabolites, reduce ethnic differences in opioid prescription types, and understand the mechanism of opioid-related adverse reactions in African American patients, which may reduce the clinical differences related to cancer pain. The scientific research cooperation network mainly includes authors, countries, and institutions. Through the analysis of their respective relationships, it is first possible to quickly locate scholars engaged in acupuncture for cancer pain, major countries, and key institutions. An intuitive introduction by research scholars also saves a lot of time and cost for them to screen countries, institutions, and author teams that undertook the same research topics. Secondly, their research found that the common shortcoming is that the cooperation between developed countries is relatively close, while the cooperation between developing countries and developed countries is not close enough. For the better development of acupuncture for cancer pain, this deficiency should be improved immediately. China is one of the developing countries, and acupuncture originated in China, while the technical methods or economic foundations of acupuncture for cancer pain in western developed countries are relatively stronger than in China. If the two can strengthen cooperation, the speed of acupuncture for cancer pain will be greatly increased, which will bring good news to patients who suffered cancer pain from all over the world and will also reduce the economic burden on society and save a lot of economic costs.

The knowledge base and research progress of acupuncture for cancer pain are described using high cocitation references and main article clusters respectively, and the co-citation frequencies of references and their importance in network nodes are shown in Table 6 . A cluster map ( Figure 5A ), (Modularity Q = 0.8287, Silhouette = 0.4054) with 325 nodes and 625 links of references was generated by CiteSpace, along with a timeline view ( Figure 5B ). The reference with the highest co-citations is Crew KD (2010) 32 35 (yoga has strong benefits for distress, anxiety, and depression, has a moderate effect on social and psychological functions and has no significant effect on physical functions and sleep disorders), massage therapy 36 (massage therapy can reduce the symptoms of cancer patients by about 50%; it can not only improve blood and lymph flow, reduce muscle tone, increase pain threshold, lower blood pressure, but also improve mood and relax the spirit), psychosocial intervention 37 (psychosocial intervention has a moderate effect on the severity of pain, and it can be used as part of a multimodal approach to pain 4 Choi TY (2012) 55 31 0. 53 Vickers AJ (1996) 67 5 Schroeder S (2012) 68 73 8 Mao JJ (2014) 74 22 0. 34 Alimi D (2003) 33 9 Bao T (2013) 75 22 0. 29 Oh B (2013) 24 10 Vickers AJ (2012) 76 21 0. 27 Bao T (2013) 75 11 Hershman DL (2014) 77 19 0. 27 Mehling WE (2007) 78 12 Paley CA (2015) 57 18 0. 21 Gorin SS (2012) 37 13 Shen JN (2000) 79 40 and nausea and vomiting caused by delayed chemotherapy in patients with gynecological cancer, 41 these are all important parts of this category. 2) Symptom management of cancer: mainly includes two aspects of #8 cancer symptom management and #11 symptom management. The symptoms involved include not only pain but also emotional stress symptoms, 42 quality of life, 43 dyspnea, nausea, vomiting, 44 and fatigue, 45 etc. The treatment methods included are not limited to acupuncture, it also includes interactive music therapy 46 (music therapy has a calming and pleasant effect on many hospitalized cancer children; interactive music therapy can reduce the anxiety of cancer hospitalized children and increase their positive emotions), hypnosis and cognitive behavioral training 47 (cognitive behavior can improve patient compliance, reduce economic costs, save time allocation, and minimize children's pain and anxiety), acupoint injection 48 (neiguan acupoint injection has the same effect as droperidol on the control of early postoperative nausea and vomiting in children), Reiki therapy 49 (Reiki therapy is a method of utilizing cosmic energy to cure diseases, maintain health, and cultivate; and it is recognized as the simplest, most efficient, most convenient and best energy therapy system in the world of natural medicine), mindfulness meditation 50 (mindfulness meditation can effectively reduce overall mood disorders and specific symptoms of anxiety, depression, anger, and confusion in patients with various cancers), etc., which are the main research content of this category. Regarding the treatment of cancer pain with acupuncture, the treatment methods involved and other related symptoms have been analyzed in other categories, so we will not repeat them here. 3) Types of diseases treated by acupuncture: including #2 early breast cancer, #7 bone pain caused by cancer, #10 chemotherapy-induced peripheral neuropathy, #14 neck malignancies, etc. The research on early breast cancer is based on acupuncture treatment of aromatase inhibitor-related arthralgia representative. Bone pain caused by cancer: Zhang RX 51 studied the therapeutic effects of electroacupuncture on bone cancer pain. The results showed that electroacupuncture can reduce the pain of bone cancer by inhibiting the expression of interleukin-1β. The results support the clinical application of electroacupuncture in the treatment of cancer pain. Chemotherapy-induced peripheral neuropathy: this peripheral neuropathy is mostly caused by chemotherapy for breast cancer or multiple myeloma. A retrospective case study 52 was conducted on the efficacy of acupuncture and reflex therapy in alleviating the symptoms of peripheral neuropathy in patients with breast cancer. 93% of the patients were effectively relieved, indicating that this therapy can be used as a preventive treatment. Han XY's research 53 concentrates on the combined treatment of acupuncture and mecobalamin for peripheral neuropathy caused by chemotherapy in multiple myeloma. 104 patients were randomly divided into a mecobalamin treatment group and acupuncture combined mecobalamin treatment group. After treatment, it was found that acupuncture combined therapy has obvious advantages in pain relief and improvement of quality of life, suggesting that acupuncture is a safe and effective treatment method. Neck malignancies: Johnstone PAS 54 intervened with acupuncture on 18 patients with xerostomia who did not respond to pilocarpine treatment due to malignant tumors of the head and neck after radiotherapy. The results showed that this therapy increased the flow rate of saliva, and acupuncture using ear and finger points helped temporarily relieve xerostomia in some patients with refractory symptoms after radiotherapy.4) #3 randomised clinical trial: Choi TY 55 conducted a systematic review of all randomized controlled trials of acupuncture for the treatment of cancer pain. The results showed that all RCT studies originated from China, and the accuracy of the results is open to question. Moreover, the total number of randomized controlled trials included in the analysis and their methodological quality is too low, and the quality of randomized controlled trials needs to be improved to obtain definite conclusions. Randomized trial studies on acupuncture also involve multicenter studies of acupuncture and the placebo effect of acupuncture treatment, which have greatly enriched the research content of cancer pain treatment. Figure 6A and Table 9 exhibit keyword co-occurrence cluster analysis, a knowledge mapping with 191 nodes and 317 keywords links and cluster view ( Figure 6B ), modular Q = 0.7353, Mean silhouette = 0.7291 are created. The modularity Q>0.3, which indicates that the results of the divided community structure are remarkable. The timeline view shows that new keywords appear almost every year. In the cluster map, the acupuncture is effective in treating adult cancer pain. DeMoss Patrick's study 58 explored the therapeutic effects of acupuncture from the perspective of amputation pain in children with bone tumors and found that comprehensive treatment methods such as psychotherapy and acupuncture may have the best effect before and immediately after amputation. Besides, the result of cluster analysis also includes the following aspects. 1) #5 lung cancer: Nobel S 59 took lung cancer as an example to study the role of acupuncture in pain management after thoracotomy. The data show that acupuncture can reduce the pain after thoracotomy, and it is well-tolerated, and the limitation of movement caused by pain is restored. 2) #7 case series: to seek complementary and alternative medicines to manage cancerrelated symptoms or side effects of treatment, Vinjamury SP 60 evaluated the feasibility of acupuncture for cancer pain through case studies. The results showed that acupuncture may improve the symptoms of cancer pain and improve the quality of life of patients. It provides a methodological basis for exploring a preliminary plan for acupuncture treatment of cancer pain. 3) #8 potential vanilloid: the most representative study in this category is the effect of ST36 (Zusanli) acupoint electroacupuncture on Walker 256 tumor-bearing rats with cancer pain and transient receptor potential vanilloid subfamily 1 expression. 61 By observing the electroacupuncture treatment by internal injection of Walker 256 cancer cells and dorsal root ganglion (DRGs) tumor-driven TRPV1 expression induced cancer pain effect, Zusanli plays an analgesic effect by inhibiting the up-regulation of TRPV1 gene and protein in DRGs, which is the mechanism of acupuncture treatment of cancer pain research provides experimental basis. 4) #13 PMAmediated MMP-9 gene activation: The most important research in this category is bee venom suppresses PMAmediated MMP-9 gene activation via JNK/p38 and NF-kBdependent mechanisms. 62 The results show that bee venom suppresses through p38 MAPK and JNK signaling pathways in MCF-7 cells. NF-kB inhibits the expression and activity of MMP-9 induced by PMA, thereby exerting anti-cancer and anti-metastasis mechanisms. This not only provides new treatment methods for cancer treatment but also provides ideas for the analysis of anti-cancer mechanisms.

There are two limitations to this study. Firstly, although the search strategy searches for synonyms of the MeSH subject words in PubMed, it may still cause some pieces of literature to be missed. Secondly, CiteSpace's function of removing duplication has certain limitations, which may bias the research results. It is just an analysis of the Web of Science database, which may not fully represent the overall trend. In addition, because some literature will be published online in advance, it will cause the inconsistency between the collection date and the publication date of this literature, so the criteria we include need to be further improved.

In this paper, we used CiteSpace to conduct scientometric analysis on acupuncture for cancer pain in the Web of Science database, and acquired the knowledge mapping of countries, institutions, authors, keywords, and cited references in this field. This study provides a new perspective on the trend of acupuncture for cancer pain. Although this study has some limitations, it fully reveals the global trend of acupuncture for cancer pain. Comparing the S values of different cluster categories, we found that the research category with the largest S value is early breast cancer, cancer-induced bone pain, and the placebo effect. Therefore, it is regarded as the most reliable research and is the hotspot of research. All in all, the results of this study may provide researchers with useful information, such as research frontiers, potential collaborators and cooperative institutions, important research content, and key references.

equally to this work and should be considered co-first authors. All authors made substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; took part in drafting the article or revising it critically for important intellectual content; agreed to submit to the current journal; gave final approval of the version to be published; and agree to be accountable for all aspects of the work.

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The authors would like to express their appreciation to Professor Chaomei Chen for inventing CiteSpace and making it free to use. 

The authors report no conflicts of interest in this work.