Mapping the research landscape of pulmonary rehabilitation in lung cancer: a bibliometric analysis [1997-2025].

Introduction
Lung cancer remains one of the most prevalent and lethal malignancies worldwide, with significant impacts on patients’ physical functioning, psychological well-being, and overall quality of life (1). According to global cancer statistics, lung cancer continues to be the leading cause of cancer-related mortality, accounting for approximately 1.8 million deaths annually (2). Despite advances in medical treatments, including surgery, chemotherapy, radiotherapy, and targeted therapies, 5-year survival rates remain relatively low, ranging from 15–25% depending on stage at diagnosis and access to treatment (3). Most lung cancer patients experience substantial symptom burden throughout their disease trajectory, including dyspnea, fatigue, pain, and reduced exercise tolerance, which significantly impair their functional capacity and independence (4). These impairments often persist or worsen following treatments such as lung resection, which can reduce pulmonary function by up to 30% (5). Consequently, rehabilitation has emerged as a critical component of comprehensive lung cancer care, with approaches ranging from physical exercise programs and respiratory muscle training to psychosocial interventions and nutritional support (6). Evidence suggests that early rehabilitation interventions can mitigate treatment-related complications, accelerate recovery, and improve long-term outcomes (7). Among various rehabilitation modalities, pulmonary rehabilitation, with its multidisciplinary approach focusing on exercise training, breathing techniques, and educational components, has shown particular promise in addressing the complex needs of lung cancer patients across different stages of care, from preoperative preparation to survivorship support (8).
The evidence supporting rehabilitation interventions for lung cancer patients has expanded substantially. Exercise-based rehabilitation programs have demonstrated improvements in cardiorespiratory fitness, muscle strength, functional capacity, and health-related quality of life (9). Moreover, prehabilitation interventions prior to lung cancer surgery have shown potential in reducing postoperative complications and length of hospital stay, thereby enhancing recovery trajectories (10). These benefits highlight the multifaceted role of rehabilitation in addressing not only physical impairments but also psychological distress, fatigue, and other symptoms commonly experienced by lung cancer patients.
Despite the growing evidence base, the implementation of rehabilitation services for lung cancer patients remains suboptimal in clinical practice. Barriers to implementation include limited awareness among healthcare providers, insufficient referral pathways, resource constraints, and gaps in the evidence regarding optimal timing, dosage, and modalities of rehabilitation interventions (4). Additionally, the heterogeneity of lung cancer populations, with varying disease stages, treatment modalities, and comorbidity profiles, presents challenges in developing standardized rehabilitation protocols (11).
The evolving landscape of lung cancer rehabilitation research reflects broader shifts in cancer care paradigms toward more holistic, patient-centered approaches that integrate biomedical treatments with supportive care interventions. This evolution has been influenced by advances in exercise oncology, increased attention to cancer survivorship issues, and recognition of the importance of maintaining functional capacity throughout the cancer continuum (12). As the field continues to mature, there is a need for systematic analysis of research trends, collaborative networks, and emerging priority areas to guide future investigations and clinical practice development.
Bibliometric analysis offers a valuable methodological approach for examining the structure, growth, and impact of scientific literature in specific domains (13). By quantitatively analyzing publication patterns, citation metrics, authorship networks, and content focus, bibliometric studies provide insights into the intellectual development and current state of research fields (14). Previous bibliometric analyses have been conducted in related areas such as cancer rehabilitation broadly (15), exercise oncology (16), and pulmonary rehabilitation for chronic respiratory diseases (CRDs) (17). However, to our knowledge, no comprehensive bibliometric analysis has specifically examined the global research landscape of pulmonary rehabilitation for lung cancer patients. In this context, the present study aims to provide a comprehensive bibliometric analysis of global research on pulmonary rehabilitation for lung cancer patients. We present this article in accordance with the BIBLIO reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1959/rc).

Methods
The Web of Science Core Collection (WoSCC), encompassing the Science Citation Index Expanded (SCIE) and the Social Sciences Citation Index (SSCI), both of which collectively index literature dating back to 1900, was used as the primary data source for this bibliometric analysis. The search covered publications from January 1, 1997, to February 13, 2025. The year 1997 was designated as the starting point because it corresponded to the earliest indexed article within WoSCC addressing pulmonary rehabilitation in the context of lung cancer, thereby marking the initiation of the research field. The search was performed on February 13, 2025, and included early-online and in-press publications available at that time, as WoSCC systematically indexes forthcoming papers that have been accepted and publicly listed. The search strategy employed a combination of terms related to lung cancer and rehabilitation interventions. Specifically, we used the following search formula: TS=(“Pulmonary Neoplasm” OR “Lung Neoplasm” OR “Lung Cancer” OR “Pulmonary Cancer”) AND TS=(“pulmonary rehabilitation” OR “respiratory rehabilitation” OR “lung rehabilitation” OR “respiratory training” OR “exercise training” OR “exercise therapy” OR “breathing exercise” OR “breathing technique” OR “aerobic exercise” OR “upper limb training” OR “resistance training” OR “balance training” OR “mobility training” OR “stretch training” OR “strength training” OR “interval training” OR physiotherapy OR “physical therapy” OR “respiratory physiotherapy” OR “respiratory physical therapy” OR “psychoeducation” OR “psychosocial support”). Only English-language articles were included, while studies published in other languages were excluded to ensure consistency and reliability in bibliometric data extraction. For this study”, pulmonary rehabilitation” was defined broadly as a multidisciplinary intervention encompassing (I) comprehensive assessment, (II) exercise training, (III) patient education, and (IV) behavioral and psychosocial support aiming to improve physical capacity, symptom control, and quality of life in lung cancer patients across different phases of care (18). This definition aligns with the American Thoracic Society/European Respiratory Society clinical practice guidelines and was applied to ensure that included studies corresponded conceptually to the intended rehabilitation framework. For each included article, the “Full record and cited references” were exported in plain-text format to extract bibliometric information such as country/region affiliations, institutional contributors, journal metrics, publication/citation data, author information, and keywords.

Statistical analysis and visualization of results
Bibliometric analyses were performed using three complementary tools: VOSviewer (version 1.6.20), CiteSpace (version 6.3.R1), and the R package “bibliometrix” (version 4.3.3). These tools facilitated quantitative analyses and visualization of bibliometric networks, research hotspots, and temporal trends. VOSviewer was employed to map and analyze collaboration networks among countries, institutions, and authors, as well as keyword co-occurrence networks (19). In VOSviewer visualizations, node size represents the frequency or importance of an element, connection line thickness reflects the strength of relationships, and colors indicate clusters or temporal groups. CiteSpace was used to detect emerging trends and research frontiers through keywordburst analysis (20). Configuration parameters included: time slicing from January 1997 to February 2025 (1-year intervals), node type = keywords, top 5 items per slice, and pruning using pathfinder and merged network techniques. This setup identified keywords with strong citation bursts, representing periods of intensive focus. The “bibliometrix” package of R was used for quantitative performance analysis and science mapping (21). This tool enabled the calculation of various indices to assess author and journal impact. The h-index reflects an author’s productivity and citation impact, defined as the maximum value of h such that the author has published h papers that have each received at least h citations (22). The g-index gives more weight to highly cited articles and is defined as the largest number g such that the top g articles received at least g2 citations (23). The m-index is calculated as the h-index divided by the number of years since the author’s first publication, providing an indication of the rate of citation accumulation (24). For journal evaluation, journal citation reports (JCR) quartiles and impact factor (IF) values were derived from the 2023–2024 JCR release (25). Journals were categorized as Q1 (top 25%, >75th percentile), Q2 (>50th to ≤75th percentile), Q3 (>25th to ≤50th percentile), and Q4 (bottom 25%, ≤25th percentile).

Results

Literature screening and selection process
Initially, 823 studies were identified from the WoSCC using a detailed search strategy combining lung cancer terms with various rehabilitation modalities. After applying exclusion criteria based on publication type and language, 369 unique records were excluded. These records included review articles (n=204), meeting abstracts (n=92), proceeding papers (n=16), editorial materials (n=14), letters (n=14), early access records (n=9), retracted publications (n=4), book chapters (n=3), corrections (n=1), and non-English publications (n=18). As publication types in the Web of Science database are not mutually exclusive, some records were indexed under multiple categories. Ultimately, 454 studies were included for analysis (Figure 1). To ensure comprehensiveness, the reference lists of the included articles were also manually screened to identify any additional eligible studies not captured in the database search; no new articles meeting the inclusion criteria were found through this process. A complete list of all 454 included publications has been provided (available online: https://cdn.amegroups.cn/static/public/jtd-2025-1959-1.xlsx). The temporal distribution of publications shows a distinct growth pattern in lung cancer rehabilitation research from 1997 to 2025. The publication trajectory demonstrates a steady increase over time. After minimal activity in the early years [1997–2005], research output began to increase notably from 2009 onwards. Significant growth occurred after 2013, with particularly productive years in 2017 (40 publications), 2024 (55 publications), and 2023 (43 publications). The data reveals some fluctuations, including notable decreases in certain years (2008, 2012, 2016, 2019, 2021), but the overall trend confirms expanding research interest in this field (Figure 2).

Country distribution and collaboration networks
Analysis of corresponding author countries reveals that China and the USA dominate research production in lung cancer rehabilitation. China leads with 87 articles (19.16% of total publications), followed by the USA with 79 articles (17.40%) and the United Kingdom with 30 articles (6.61%). In terms of total publications (TP), the USA ranks first (357 publications), followed by China (321 publications) and Australia (154 publications). For total citations (TC), the USA again leads with 3,655 citations, Belgium ranks second with 1,971 citations despite having fewer publications, and Canada ranks third with 1,262 citations. Regarding publication quality as measured by average citations per paper, Belgium demonstrates exceptional impact with 197.1 citations per publication, followed by Canada (66.4) and Switzerland (61.5). Notably, some countries with fewer publications show higher citation impact, suggesting focused, high-quality contributions (Figure 3A, Table S1).
The visualization map of country collaboration networks (Figure 3B) depicts a robust international research ecosystem in lung cancer rehabilitation. Among the 44 countries involved in international collaborations, the USA demonstrates the strongest collaborative network with 61 collaborative links to other countries, followed by Canada [51] and Italy [49]. The network analysis reveals several distinct research clusters indicated by different colors, with stronger collaborative ties illustrated by thicker connection lines. The total link strength metric quantifies collaboration intensity, with the USA (4,953 citations across 103 documents), Canada (3,703 citations across 34 documents), and Italy (3,121 citations across 28 documents) forming the core of the international research network. Despite having the highest number of publications, China shows a relatively lower international collaboration rate, with only 8.05% of its publications involving international co-authorship, compared to Brazil (100%), Belgium (50%), and Switzerland (50%), which demonstrate the highest rates of international collaboration.

Leading institutional contributors to lung cancer rehabilitation research
The institutional analysis reveals a clear concentration of research productivity in certain leading centers specializing in lung cancer rehabilitation. The University of Copenhagen demonstrates exceptional output with 69 articles, establishing itself as the foremost institution in this field. Sichuan University follows with 39 articles, while Université de Rouen Normandie ranks third with 34 articles. Among the top 10 most productive institutions, Harvard University (30 articles) and CHU de Rouen (26 articles) round out the top 5. The distribution pattern shows a mix of European, Asian, and North American institutions dominating the research landscape, reflecting the global importance of this research area (Table S2, Figure 4A).
The visualization of institutional collaboration networks (Figure 4B) displays a complex and interconnected research ecosystem. Among the 225 institutions involved in collaborative research with a minimum of 2 articles, the University of Melbourne demonstrates the strongest collaborative profile with 49 total link strength, despite having only 14 documents (235 citations). Memorial Sloan Kettering Cancer Center follows closely with 47 total link strength (14 documents, 725 citations), and The Royal Melbourne Hospital ranks third (27 total link strength, 8 documents, 124 citations). The network visualization reveals several distinct research clusters indicated by different colors, with major hubs including University Melbourne, Memorial Sloan Kettering Cancer Center, University of Texas MD Anderson Cancer Center, Duke University, and Peter MacCallum Cancer Center, which form the core of the institutional research network.

Journal impact analysis in pulmonary rehabilitation for lung cancer
The analysis of journal bibliometric indicators identifies the most influential publication outlets in lung cancer rehabilitation research. Lung Cancer emerges as the most influential journal with an H-index of 15, a g-index of 17, and an m-index of 0.75, publishing 17 articles that have accumulated 551 citations. Supportive Care in Cancer ranks second with an H-index of 12, having published 16 articles with 444 total citations. The European Journal of Cardio-Thoracic Surgery completes the top 3 with an H-index of 10 (379 citations across 11 articles). Regarding impact factor, Journal of Thoracic Oncology leads significantly with an IF of 21, followed by British Journal of Anaesthesia (IF =9.1) and Cancer (IF =6.1) (Table S3).
The co-occurrence network analysis of journals reveals their interconnectedness within the field. Among the 225 journals with at least one occurrence, Lung Cancer demonstrates the highest total link strength [293] in co-occurrence networks, followed by European Journal of Cardio-Thoracic Surgery [153] and BMC Cancer [96] (Figure 5A). The coupling network analysis provides insights into journals sharing similar intellectual foundations. The analysis identifies Lung Cancer (total link strength: 4,009), BMC Cancer [3,900], and Supportive Care in Cancer [2,667] as the three journals with the strongest bibliographic coupling (Figure 5B).

Key author contributions and collaboration networks in lung cancer rehabilitation
The bibliometric indicators of high-impact authors reveal the leading researchers shaping the field of lung cancer rehabilitation. Jones Lee W. emerges as the most prolific and influential author with 14 publications (highest TP), an H-index of 14 (highest among all authors), and 129 total citations (highest TC). Denehy Linda, Eves Neil D., and Granger Catherine L. share the second position in terms of author impact with an H-index of 8 each. Che Guowei ranks second in productivity with 10 publications, followed by Lai Yutian and Granger Catherine L. with 9 publications each. The author impact analysis also reveals interesting variations in citation patterns, as seen with Ma Rui-Chen who, despite having a modest H-index of 4, ranks significantly lower in total citations (TC rank =797) (Table S3).
The visualization of author collaboration networks displays an intricate ecosystem of research partnerships in lung cancer rehabilitation. Among the 107 authors with a minimum of 3 articles, Bonnevie Tristan, Boujibar Fairuz, and Gravier Francis-Edouard demonstrate the highest collaboration intensity with 34 total link strength each, despite having only 5 publications and 92 citations each. Jones Lee W., despite being the most productive author, ranks 6th in collaboration strength (31), tied with Langer Seppo W., Baste Jean-Marc, and Debeaumont David. The network visualization reveals several distinct research clusters indicated by different colors, with major collaborative hubs formed around authors like Che Guowei (total link strength: 27), Lai Yutian [26], and Jones Lee W. [31] (Figure 6).

Most cited articles in lung cancer rehabilitation
The most cited article was published in Clinical Nutrition (IF =6.6) in 2017 and has accumulated 1,817 citations (26). This influential work established evidence-based nutritional guidelines for cancer patients, including those with lung cancer, providing comprehensive recommendations for nutritional care throughout various treatment phases. The second most cited article was published in the British Journal of Cancer (IF =6.4) in 2004 and has garnered 680 citations (27). This landmark study documented the prevalence of psychological distress and fatigue among cancer patients, revealing significant gaps in supportive care and highlighting the need for integrated psychosocial interventions during cancer treatment and rehabilitation. The third most influential publication appeared in the American Journal of Respiratory and Critical Care Medicine (IF =19.3) in 2015 and has received 537 citations (28). This authoritative policy statement from major respiratory societies provided a framework for enhancing implementation and delivery of pulmonary rehabilitation services, establishing standards that have significantly influenced clinical practice for lung cancer patients.

Thematic evolution and research hotspots in lung cancer rehabilitation
In total, 108 keywords with a minimum of 3 occurrences were identified. “Keywords” was observed to provide more accurate results and was selected as the primary data source for analysis. The most frequently occurring keywords were “lung cancer” (174 occurrences, total link strength 380), “pulmonary rehabilitation” (75 occurrences, total link strength 178), “quality of life” (56 occurrences, total link strength 166), “exercise” (45 occurrences, total link strength 137), and “rehabilitation” (37 occurrences, total link strength 107). VOSviewer cluster analysis revealed ten distinct keyword clusters, representing different research domains within lung cancer rehabilitation. These clusters included: (I) psychosocial support and quality of life; (II) cardiopulmonary function and pulmonary rehabilitation; (III) symptom management; (IV) perioperative interventions; (V) chest physiotherapy and assessment; (VI) advanced cancer management; (VII) nutrition and exercise in cancer; (VIII) exercise modalities; (IX) cardiorespiratory training; and (X) physical function assessment (Figure 7A).
To identify emerging trends and research hotspots, CiteSpace was employed for burst detection analysis of keywords (Figure 7B). This analysis identified 20 keywords with the strongest citation bursts across the study period [1997–2025]. Early bursts [2007–2014] centered around foundational physiological concepts, including “exercise capacity” (burst strength 3.3, 2007–2010), “cardiorespiratory fitness” (burst strength 3.07, 2008–2012), and “aerobic exercise” (burst strength 2.83, 2008–2014). These bursts reflect the establishment of basic research approaches and outcome parameters in the field’s development. The middle period [2009–2018] featured bursts in “preoperative pulmonary rehabilitation” (burst strength 4.09, 2009–2017), “survivors” (burst strength 3.27, 2011–2018), “randomized controlled trial” (burst strength 5.03, 2014–2018), and “exercise intervention” (burst strength 3.14, 2016–2019). This pattern suggests methodological advancement with increasing research rigor and expanding focus on long-term outcomes. Recent burst trends (2019-2025) have included “guidelines” (burst strength 5.26, 2019–2023), “depression” (burst strength 4.27, 2019–2022), “care” (burst strength 3.33, 2020–2023), “statement” (burst strength 4.56, 2021–2025), and “non-small cell lung cancer” (burst strength 3.28, 2022–2025). These burst patterns indicate a shift toward clinical implementation, standardization of practice, integration of psychosocial aspects, and more tailored approaches for specific lung cancer subtypes.

Discussion
This bibliometric analysis provides comprehensive insights into the global research landscape of lung rehabilitation for lung cancer patients from 1997 to 2025. Our findings revealed a steady growth in scientific output with an 8.94% annual growth rate, reflecting increasing recognition of rehabilitation’s importance within lung cancer care. The identification of 454 publications from 44 countries/regions demonstrates the global nature of this research field, though with notable concentration in specific geographical areas. The evolution of research themes over time, as evidenced by our keyword analysis, indicates a progressive shift from foundational physiological studies toward more comprehensive, patient-centered approaches spanning the entire cancer continuum. Particularly noteworthy is the recent emphasis on implementation science, clinical practice guidelines, and psychological aspects of rehabilitation, suggesting maturation of the field toward clinical application (29).
The average citation rate of 33.79 per document indicates substantial impact of research in this field, though with considerable variation across countries and institutions. The relatively high proportion of international collaborations (18.28%) suggests growing recognition of the value of cross-cultural approaches in developing widely applicable rehabilitation protocols. However, the concentration of research in high-income countries highlights potential gaps in knowledge regarding rehabilitation approaches suitable for resource-constrained settings. As lung cancer incidence continues to rise globally, particularly in low- and middle-income countries, addressing these gaps represents an important future direction (30).
The marked increase in publication volume since 2013, particularly the sharp rise between 2017–2024, coincides with several significant developments in lung cancer treatment, including the widespread adoption of minimally invasive surgical techniques, expansion of targeted therapies, and implementation of immunotherapy. These therapeutic advances have extended survival for many patients, increasing the population potentially benefiting from rehabilitation interventions and heightening interest in functional outcomes beyond survival alone (31). Additionally, the publication of influential clinical practice guidelines during this period, such as the American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation (32) and enhanced recovery after surgery (ERAS) guidelines for lung surgery (33), likely stimulated research interest and standardization of rehabilitation approaches.
The three most cited papers in lung cancer rehabilitation research have profoundly shaped the field’s trajectory. The 2017 nutritional guidelines (1,817 citations) established essential standards for nutritional care in cancer patients (26), while the 2004 study on psychological distress (680 citations) highlighted the critical need for addressing psychosocial needs during rehabilitation (27). The 2015 respiratory society policy statement (537 citations) provided the implementation framework that bridged research and clinical practice (28). Together, these works reflect the field’s evolution from identifying rehabilitation needs to establish evidence-based interventions and implementation standards.
The global research landscape reveals important patterns in lung cancer rehabilitation development. China and the USA’s dominance in publication output mirrors their leadership in cancer research broadly (30), while Belgium’s exceptional citation impact suggests influential contributions despite fewer publications. This aligns with the observation that research quality metrics often differ from quantity measures in oncology research (34). The prominence of European centers like University of Copenhagen parallels Europe’s strong tradition in pulmonary rehabilitation research (35), while Sichuan University’s leadership reflects China’s growing investment in rehabilitation medicine (36). Bibliometric analysis identified Lee W. Jones as one of the most influential authors in this field. His extensive contributions to exercise oncology have played a pivotal role in establishing exercise interventions as a cornerstone of cancer rehabilitation (37). The prominence of journals spanning oncology, supportive care, and rehabilitation medicine underscores the field’s multidisciplinary nature, consistent with current evidence suggesting integrated approaches yield superior outcomes in lung cancer care. These bibliometric indicators collectively point to an increasingly collaborative international research community focusing on translating discoveries into standardized clinical approaches.

Research hotspots and frontier trends
Understanding the evolving landscape of lung rehabilitation for lung cancer patients requires careful analysis of keyword co-occurrence networks and research clustering patterns. Our comprehensive bibliometric analysis revealed ten distinct clusters representing different research priorities and frontier trends in this field.

Cluster 1: psychosocial support and quality of life (15 items)
This cluster encompasses research centered around keywords including “advanced lung cancer”, “aerobic exercise”, “anxiety”, “breast cancer”, “chemotherapy”, “depression”, “functional capacity”, “gastric cancer”, “psycho-oncology”, “quality of life”, “radiotherapy”, “respiratory training”, “smoking”, “supportive care”, and “survivorship”. Quality of life has emerged as a critical outcome measure in lung cancer rehabilitation, with studies documenting the multidimensional nature of patient experiences (38). Research using psycho-oncology frameworks has addressed the high prevalence of depression and anxiety among lung cancer patients, with documented rates of 33% and 47% respectively (39). The integration of supportive care within comprehensive rehabilitation has shown benefits for psychological wellbeing, particularly when addressing smoking cessation, which remains a significant challenge in this population (40). Survivorship research has increasingly recognized the long-term supportive care needs of advanced lung cancer patients undergoing chemotherapy and radiotherapy (31).

Cluster 2: cardiopulmonary function and pulmonary rehabilitation (13 items)
This cluster focuses on “chronic obstructive pulmonary disease”, “COPD”, “exercise capacity”, “health-related quality of life”, “lung cancer surgery”, “outcomes”, “physical fitness”, “pneumonectomy”, “postoperative pulmonary rehabilitation”, “preoperative physiotherapy”, “pulmonary rehabilitation”, “respiratory failure”, and “surgical resection”. Research has documented significant impairments in exercise capacity among lung cancer patients, particularly those with comorbid chronic obstructive pulmonary disease (COPD), with values typically 30–40% below age-predicted norms (4). Studies examining pulmonary rehabilitation have demonstrated improvements in health-related quality of life following lung cancer surgery, including pneumonectomy and other surgical resections (41). Preoperative physiotherapy interventions have shown potential in reducing postoperative pulmonary complications and respiratory failure (42).

Cluster 3: symptom management (13 items)
This cluster encompasses keywords including “dyspnea”, “exercise”, “fatigue”, “neoplasms”, “pain”, “pre-rehabilitation”, “preoperative”, “qualitative research”, “rehabilitation medicine”, “respiratory tract tumors”, “systematic review”, “telemedicine”, and “thoracic surgery”. Dyspnea management has been extensively investigated, with studies documenting its multidimensional nature encompassing sensory intensity, affective distress, and impact on functional activities (43). Exercise interventions have demonstrated efficacy in managing cancer-related fatigue, which affects up to 90% of lung cancer patients (44). Pain assessment and management strategies have been examined through qualitative research methodologies, providing deeper insights into patient experiences (45). Systematic reviews have synthesized evidence on pre-rehabilitation approaches prior to thoracic surgery, with telemedicine emerging as a promising delivery model for remote symptom monitoring (46).

Cluster 4: perioperative interventions (12 items)
Keywords in this cluster include “caregiver”, “exercise training”, “feasibility”, “functional status”, “lung resection”, “non-small cell lung cancer”, “physical activity”, “physical therapy”, “postoperative morbidity”, “prehabilitation”, “preoperative care”, and “safety”. Studies have explored the feasibility and safety of exercise training prior to lung resection for non-small cell lung cancer, with evidence supporting the implementation of prehabilitation programs (47). Physical activity interventions have demonstrated improvements in functional status and reductions in postoperative morbidity, with emerging research examining dose-response relationships (48). The role of caregivers in supporting perioperative rehabilitation has gained increased attention, particularly in facilitating home-based interventions and enhancing adherence (49).

Cluster 5: chest physiotherapy and assessment (12 items)
This cluster focuses on “chest physiotherapy”, “incentive spirometry”, “lobectomy”, “lung cancer”, “meta-analysis”, “pneumonia”, “postoperative complications”, “pulmonary function”, “pulmonary rehabilitation”, “respiratory physiotherapy”, “thoracotomy”, and “VATS” (video-assisted thoracoscopic surgery). Research has examined the efficacy of various chest physiotherapy techniques in preventing postoperative complications following lobectomy and thoracotomy procedures (50). Incentive spirometry has been investigated extensively, though with mixed evidence regarding its effectiveness when used in isolation (51). Meta-analyses have synthesized evidence on pulmonary function assessment methods, with studies documenting the substantial impact of lung resection on respiratory parameters (52). Comparisons between VATS and open surgical approaches have examined differential impacts on respiratory physiotherapy needs and recovery trajectories (53).

Cluster 6: advanced cancer management (11 items)
Keywords in this cluster include “advanced cancer”, “aging”, “breathlessness”, “cancer”, “chronic obstructive”, “clinical trials”, “lung diseases”, “oncology”, “palliative care”, “pulmonary disease”, and “social support”. Research has documented the substantial symptom burden in advanced cancer, with breathlessness affecting up to 90% of patients with progressive disease (54). A study has explored the complex interactions between aging, cancer, and chronic obstructive pulmonary disease, with evidence that comorbidity patterns significantly impact rehabilitation outcomes (55). Clinical trials have evaluated integrated palliative care approaches, with evidence of improved quality of life and symptom management (56). Research on social support interventions has demonstrated their importance in enhancing coping strategies and reducing psychological distress among patients with advanced lung diseases (57).

Cluster 7: nutrition and exercise in cancer (10 items)
This cluster encompasses “cachexia”, “cancer cachexia”, “elderly”, “muscle strength”, “non-small-cell lung cancer”, “pancreatic cancer”, “physical exercise”, “radical treatment”, “resistance training”, and “survival” Cancer cachexia, characterized by involuntary weight loss and muscle wasting, affects approximately 60% of lung cancer patients and is associated with reduced survival (58). Research has documented significant reductions in muscle strength even in patients without overt cachexia, particularly among elderly populations (59). Physical exercise interventions, especially resistance training, have shown potential to counteract muscle wasting and improve functional outcomes (60). Studies have explored similarities in cachexia mechanisms between lung and pancreatic cancers, informing intervention development for both populations (61). Radical treatment approaches have been examined in relation to nutritional status and exercise capacity, with evidence that pre-treatment optimization may enhance tolerance and recovery (62).

Cluster 8: exercise modalities (8 items)
Keywords in this cluster include “active cycle of breathing”, “breathing exercises”, “exercise therapy”, “exercise tolerance”, “lung neoplasms”, “NSCLC”, “rehabilitation”, and “self-efficacy”. Research has examined various breathing exercise modalities, including the active cycle of breathing technique, with evidence supporting their role in symptom management and functional improvement (63). Exercise therapy approaches have been evaluated across different phases of the cancer continuum, with studies exploring optimal parameters for enhancing exercise tolerance in patients with non-small cell lung cancer (NSCLC) (12). The concept of self-efficacy has received increasing attention as a mediator of rehabilitation outcomes, with interventions incorporating motivational strategies to enhance confidence and adherence (64).

Cluster 9: cardiorespiratory training (8 items)
This cluster focuses on “cardiorespiratory fitness”, “dyspnoea”, “exercise intervention”, “inspiratory muscle training”, “physiotherapy”, “postoperative”, “randomized controlled trial”, and “surgery”. Cardiorespiratory fitness has been established as a significant predictor of surgical outcomes and overall survival, with studies documenting the prognostic value of baseline assessments (65). Exercise interventions targeting cardiorespiratory parameters have been evaluated through randomized controlled trials, with evidence supporting both continuous and interval training approaches (66). Inspiratory muscle training has demonstrated improvements in respiratory muscle strength and reduction in dyspnoea in the postoperative period (67). Physiotherapy interventions specifically designed for the post-surgical phase have shown benefits for recovery trajectories and functional outcomes (68).

Cluster 10: physical function assessment (6 items)
Keywords in this cluster include “high-intensity interval”, “lung function”, “nursing”, “perioperative period”, “physical function”, and “postoperative rehabilitation”. High-intensity interval training has been investigated as an efficient approach to improving cardiorespiratory fitness in the perioperative context, with evidence suggesting enhanced effectiveness compared to moderate continuous training (69). Physical function assessment has been operationalized through various performance-based measures, providing clinically feasible tools for monitoring rehabilitation progress (70). The nursing role in perioperative rehabilitation has received increasing attention, with research exploring nurse-led assessment and coordination of multidisciplinary care (71). Studies examining lung function parameters have identified their value in predicting rehabilitation responses and guiding intervention modifications (32).
The analysis of keyword bursts provides valuable insights into the temporal evolution of research focus in lung cancer rehabilitation. Our study identified several significant citation bursts across different time periods from 1997 to 2025, illustrating the shifting landscape of research priorities in this field.
In the early period [2007–2010], research interest focused primarily on “exercise capacity”, reflecting the foundational work establishing the importance of functional assessment in lung cancer patients. This period saw the emergence of standardized exercise testing protocols and the documentation of significant impairments in cardiorespiratory fitness among newly diagnosed patient (72). Between 2008 and 2012, “cardiorespiratory fitness” emerged as a research hotspot, with studies demonstrating its prognostic significance for treatment outcomes and survival (73). The period from 2008 to 2014 witnessed sustained interest in “aerobic exercise” interventions, as researchers explored various training modalities and their effects on physiological outcomes and quality of life. During this time, several influential trials established the safety and preliminary efficacy of supervised exercise programs for lung cancer patients across different treatment phases (74).
From 2009 to 2017, “preoperative pulmonary rehabilitation” gained significant traction, showing one of the strongest burst intensities (4.09) in our analysis. This surge reflected growing recognition of the potential benefits of prehabilitation in reducing postoperative complications and enhancing recovery trajectories (75). Concurrent with this trend, research on “survivors” [2011–2018] and “cardiopulmonary function” [2013–2014] underscored the expanding focus on long-term outcomes and physiological mechanisms. The period from 2014 to 2018 featured intense research activity around “randomized controlled trials”, representing the field’s maturation with more rigorous methodological approaches. This surge corresponded with the publication of several landmark trials examining exercise interventions in different contexts of lung cancer care (76). The burst in “disease” keywords [2015–2017] reflected increased attention to comorbidity management and disease-specific considerations in rehabilitation programming.
More recent bursts included “exercise intervention” [2016–2019], “postoperative complications” [2017–2018], “lung neoplasms” [2017–2018], and “thoracic surgery” [2017–2021], indicating continued refinement of perioperative rehabilitation approaches. The burst in “thoracotomy” research [2018–2019] highlighted specific attention to recovery following this surgical procedure, particularly regarding pain management and shoulder function (77). Since 2019, several notable bursts have emerged, including “guidelines” (2019–2023, burst strength 5.26), “depression” (2019–2022, burst strength 4.27), and “risk” (2019–2022, burst strength 3.76). The strong burst in guidelines research reflects efforts to standardize rehabilitation practices based on accumulating evidence, with several professional organizations publishing consensus statements during this period (78). The focus on depression underscores increasing recognition of psychosocial aspects in comprehensive rehabilitation programming.
The most recent bursts, occurring from 2020 to 2025, include “care” [2020–2023], “statement” [2021–2025], “program” [2022–2025], and “non-small cell lung cancer” [2022–2025]. These trends indicate ongoing development of structured rehabilitation programs specifically tailored for non-small cell lung cancer patients, the most common histological subtype (79). The burst in “statement” research parallels increasing publication of position papers and clinical practice recommendations from professional societies, reflecting maturation of the evidence base and efforts to enhance clinical implementation.

Future research directions beyond 2025
Based on our bibliometric analysis and emerging patterns in the most recent literature, several key research trends are likely to shape lung cancer rehabilitation beyond 2025. First, the integration of digital health technologies, including wearable devices, telerehabilitation platforms, and artificial intelligence-assisted personalization, will likely transform rehabilitation delivery models (80). Second, immunotherapy’s growing role in lung cancer treatment necessitates specific rehabilitation approaches addressing unique side effect profiles and treatment trajectories (81). Third, precision rehabilitation incorporating genetic, molecular, and phenotypic data to tailor interventions to individual patients will likely gain prominence (82). Fourth, implementation science will become increasingly important as researchers focus on translating evidence into routine clinical practice across diverse healthcare settings (83). Finally, as survivorship extends for advanced lung cancer patients, research into long-term rehabilitation needs and late effects management will expand, building on Presley et al.’s work on the changing survivorship landscape for this population (31). These emerging directions suggest a future where lung cancer rehabilitation becomes increasingly precise, technology-enabled, accessible, and integrated throughout the entire cancer continuum.

Strengths and limitations
This bibliometric analysis has several notable strengths. First, the comprehensive search strategy spanning nearly three decades [1997–2025] provided a thorough overview of research evolution in lung cancer rehabilitation. Second, the application of multiple complementary bibliometric tools (VOSviewer, CiteSpace, and R Bibliometrix) allowed for triangulation of findings through different analytical approaches. Third, the examination of multiple bibliometric indicators—including publication patterns, citation impact, collaboration networks, and keyword trends—provided multidimensional insights into the field’s development. Fourth, the cluster analysis of keywords offered nuanced understanding of research subdomains and their interconnections. Finally, the burst detection analysis enabled precise identification of emerging research trends and shifting priorities over time.
Several limitations should be acknowledged when interpreting our findings. First, although we used a comprehensive search strategy, our reliance on a single database (WoSCC) may have resulted in overlooking some relevant publications, particularly those in non-indexed journals or languages other than English. This decision was based on the WoSCC’s established advantages in citation accuracy, standardized indexing, and long-term coverage across the Science Citation Index Expanded and Social Sciences Citation Index databases, making it the most commonly used data source for high-quality bibliometric studies in medical research (84,85). Prior studies in this journal have also adopted a single WoSCC-based approach for bibliometric analyses to ensure consistency and data comparability. Nevertheless, future research could integrate additional databases such as Scopus or PubMed to broaden coverage and enhance data validation. Second, bibliometric analyses inherently favor established research areas and may underrepresent emerging topics that have not yet accumulated substantial citation metrics. Third, differences in citation practices across research domains may influence comparative interpretation of citation-based metrics. Fourth, the focus on quantitative indicators of research impact does not necessarily capture qualitative aspects of research significance or clinical relevance. Fifth, the keyword analysis is limited by variations in terminology and indexing practices across journals and time periods. Finally, interpretation of research trends is constrained by the inherent lag between research conduct and publication, potentially underestimating very recent developments in the field.

Conclusions
This bibliometric analysis reveals the evolution of lung cancer rehabilitation research [1997–2025], showing substantial growth and methodological advancement. Key research hotspots include psychosocial support integration, perioperative rehabilitation, symptom management, and exercise prescription. The field has progressed from establishing physiological principles toward clinical practice standardization and implementation science. Recent trends emphasize guideline development, depression management, integrated care models, and tailored approaches for specific patient subgroups. With China and the USA leading publication output and increasing international collaboration, these findings provide strategic direction for advancing rehabilitation approaches throughout the lung cancer care continuum.

Supplementary
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