THE STATE FROM ITS MARGINS: A PERSPECTIVE FROM STREET LEVEL TURKEY

Interview with Elise Massicard (Sciences Po, Centre de recherches internationales (CERI), CNRS, Paris, France), by Miriam Périer

In : Les Entretiens du CERI, 16 June 2022 URL : https://www.sciencespo.fr/ceri/en/content/state-its-margins-perspectivestreet-level-turkey-interview-elise-massicard.html Muhtars, the lowest-level elected political position in Turkey, hold an ambiguously defined place within the administrative hierarchy. Research Professor at CERI Elise Massicard is the author of Street-Level Governing (Stanford University Press ), the first book to investigate how muhtars carry out their role-not only what they are supposed to do, but how they actually operate-providing an ethnographic study of the state as viewed from its margins. She answers our questions on the muhtar as a hybrid object and her research.

The book focuses on the figure of the muhtar in Turkey, a "hybrid object" as you call it. What are, in broad terms, muhtars main functions and official missions? I call muhtars "hybrids" because they don't "fit into any box". The muhtars are local public agents, at the neighbourhood or village level. They are the authorities' auxiliaries in various fields (public services, public order, social assistance). But they are not bureaucrats in Weber's sense: they do not have the status of civil servants, and they are not permanent; they are in fact elected by the population for five years. From this point of view, they are more like local elected representatives-and indeed, they bring the population's demands for services and needs to the attention of the public authorities. But they are not exactly local elected officials like others; they do not have the capacity to represent the population. Moreover, since the 1980 coup, they are no longer elected on party labels, but on different, micro-local logics. It is therefore difficult to classify the muhtar in the classic categories of political sociology (field administrator, local elected official, street-level bureaucrat...). Beyond merely being intriguing, this observation raises interesting scientific questions. In particular, the one that aroused my interest is related to the fact that muhtars are precisely situated at the intersection of bottom-up and top-down logics. This makes them a very heuristic observation point for understanding the state-society relations.

What led you to investigate this figure in Turkish local politics? Was it because of their ambiguous position, their status as a "boundary figure"?

This interest stemmed from a more general questioning. It is commonly considered-not only in the media and political circles, but also in scientific literature-that the Turkish state is a strong state, which is autonomous from society. This idea is so widespread that it is rarely questioned. However, some colleagues-fellow historians, anthropologists, geographers, and others-and I were not satisfied with this idea, because what we observed in our various research contradicted this idea. My interest in the muhtar arose from this questioning of the autonomy of the state, in relation to society, not only in Turkey but also more broadly. I wanted to look precisely at a touchpoint between "state" and "society". The muhtars are very versatile connection points, because they deal with different areas of activity and, beyond their official competences, citizens have recourse to them for all sorts of issues. Above all, the muhtar is the daily contact point, the first official instance of referral, and I wanted to move away from a sectoral and event-based analysis and look at the banality of everyday life.

Is this because of muhtars' contribution to politics from below?

Precisely. I find their contribution to "politics from below" interesting in two dimensions. Firstly, because the muhtarlık-the institution linked to the muhtar-represents the extremity of the capillarity of the state. It is therefore the place of officialdom furthest from the political centre, the one most in touch with society. The second dimension is that "politics from below", as theorised by Bayart, Mbembe, and Toulador, but which is close to what others have called infrapolitics (James Scott) or low politics (Asef Bayat), is generally studied outside institutions and formal, institutional politics. The literature tends to consider that politics from below has an anti-hegemonic effect-even nature-by definition. Through the muhtar, I wanted to study politics from below in a different way, within an institutional, official framework. However, the book shows that a mechanism such as the muhtar, depending on the way it is used, can indeed have anti-hegemonic effects but can also, under certain conditions, reinforce institutional domination. Consequently, the anti-hegemonic dimension is not consubstantial with politics from below; it depends on where such a politics from below is observed and the tools with which it is analysed.

You mention the many ways in which people get around the forms of domination imposed on them. Can you tell us more about this?

As we understand it, the muhtar (and more broadly the institution of the muhtarlık) is the official figure who is most in touch with society.

However, this institution is little codified and little controlled. The ways in which muhtars and citizens use this institution are very flexible and differentiated. It is precisely these uses that determine what the institution produces in political terms. In order to understand these effects, I observed several muhtars and their daily interactions and relations with local inhabitants. In particular, they are elected, and to be re-elected, muhtars need the support of the inhabitants. I observed that the relations that citizens have with the muhtar are quite different from those they have with other public agents. Muhtars are probably the only public officials on whom local inhabitants can exercise some form of power. Of course, muhtars have integrated (like all elected officials!) the imperative of satisfying their inhabitants. This is also the reason why they do not behave like field bureaucrats, for example, but present themselves as serving the inhabitants. This has very concrete effects. For example, while muhtars are supposed to enforce the law, they do not always show much diligence in this task. They are quick to bend the rules to satisfy local inhabitants. The inhabitants know this very well, and they make use of it; it is even often precisely for this reason-for a favour, for a helping hand-that people resort to the muhtar. In short, muhtars are one of the privileged recourses in strategies for circumventing rules.

What was your research methodology for this work on muhtars? Did you encounter any significant difficulties, and what strategies did you adopt to resolve them?

This type of research presents specific difficulties. Firstly, because muhtars are often considered to be powerless and therefore insignificant, there is very little research on them-this could be generalised to other grassroots intermediary figures in other countries, who are structurally understudied. I had little scientific literature to draw on. Secondly, there are very few other written sources on them, apart from the legislative texts that provide a framework for their practice-but which are far from being systematically applied. Finally, their practice is mostly oral and leaves little written record. Everything therefore depended on the field survey. This seemed easy at first sight: muhtars are public persons and accessible to everyone. On the other hand, they have a public image to maintain with their constituents and voters. It was difficult to get past their self-presentation, especially in interviews. To get around this difficulty, I focused on two things: firstly, observation. I spent a lot of time in muhtars' premises, looking at what was happening there on a daily basis and their interactions with the local people. The muhtars were often reluctant to accept my presence during their interactions with residents; I sometimes had to impose myself to a certain extent. Secondly, the duration. I sampled a limited number of muhtars, visiting them at regular intervals over a long period of time, gradually building trust. This enabled me to observe changes and to go beyond the image they wanted to give of their activity. But this way of doing research was only made possible by my presence on the spot for several years. This type of research is not feasible at a distance, nor with short field stays.

Interview by Miriam Périer, CERI


ou non, émanant des établissements d'enseignement et de recherche français ou étrangers, des laboratoires publics ou privés.

HOW IS THE OTHER PERCEIVED?

Interview with Catherine Wihtol de Wenden (Sciences Po, Centre de recherches internationales (CERI), CNRS, Paris, France), by Miriam Périer In : Les Entretiens du CERI, 15 July 2022 URL : https://www.sciencespo.fr/ceri/en/content/how-other-perceived-interviewcatherine-wihtol-de-wenden.html

In her book Figures de l'Autre. Perceptions du migrant en France, 1870-2022, published in July 2022 by CNRS Éditions, Catherine Wihtol de Wenden offers what she describes as a "second-degree" exploration of immigration in France through the ways in which this social issue is perceived and how it is conveyed in images. She shows how the collective memory of the immigrant Other has been built up over the years, since 1870. Catherine Wihtol de Wenden answers our questions.

The book covers a period from 1870 to 2022. Why did you start the study in 1870? What events characterise this year and how does the issue of migration come into play? CNRS Éditions invited me a long time ago to write a book on how immigration is represented, while I was working on different aspects of this research subject. I chose to treat the issue as a research itinerary, through four decades of work. I chose to start in 1870 because there are hardly any texts on the "immigrant Other" for this period, except for the most famous figures in French history, such as the queens and their entourages or those who played a notable role before the 1870s (Catherine de Medicis, Concino Concini, Mazarin, Marie-Antoinette, John Law, Thomas Paine, Anacharsis von Clootz). The collective rather than individual figure of the Other that emerged in 1870 was that of the Prussian, ascribed with all the attributes of the "barbarian", an abstract construct based on ethnic and linguistic belonging to the Germanic world, as opposed to the French figure of Marianne , who represented the non-ethnicised republican values of the social contract and the ideals of the French Revolution. This period also marks the beginnings of labour immigration to the mines of the North and Lorraine (Émile Zola alludes to the Belgians in Germinal), to the salt mines of the South (let us remember the massacre of the Italians in 1893), and to large urban construction sites (the Goutte d'Or district in Paris emerged during the construction of the Gare du Nord and Gare de l'Est railway stations, which began in the middle of the nineteenth century), or in the context of nascent industrialisation. Images of the "immigrant" Other multiplied, even though the distinction between nationals and foreigners was still in its early stages, since rights were not yet strongly differentiated between the two and people from the French provinces were sometimes saddled with the same stereotypes (Auvergnats, Bretons) when they arrived in Paris.

The end of the nineteenth century was characterised by the beginning of intervention by the public authorities, who were anxious to "make French people out of foreigners" by widening access to nationality (based on the jus soli and jus sanguinus since 1889) because of the Germans' feared demographic growth and the decline of the French population in the event of conflict.

You suggest four periods for this study, can you say a few words about them? Did each period produce a figure of the Other?

The first period extends from 1870 to the First World War: France is the only European country to be a country of immigration, its neighbours being countries of emigration not only to France, but also to the Americas or Australia. The French migrated rarely, but the colonial phenomenon somewhat masked their movements towards Africa or Asia.

After the arrival of refugees from the First World War (Armenians, Russians, "Levantines" from the Ottoman Empire), the interwar period was marked by the rise of virulent xenophobia and anti-Semitism, which was widely reported in the press and public opinion. This was against a backdrop of economic crisis in the 1930s, the closure of immigration in 1932, and the reluctant reception of refugees from authoritarian regimes (Italians, Germans, Spaniards), before some of them took part in resistance movements.

The period 1945-1975 saw the rejection of the Other fade away, against a backdrop of economic prosperity and labour needs, at a time when the world of labour and trade unions was seeking to forge links with foreign workers in the name of the unity of the working class against discrimination, and when the question of migration was highly depoliticised. In 1974, the oil crisis and the conflict between the French and Algerians led to Algeria stopping its immigration and France suspending the immigration of salaried workers in 1974, after the election of Valéry Giscard d'Estaing. This is when an immigration and integration policy began to appear. However, no law was passed on the subject between 1945 and 1980. This was the so-called "infra-law", which was dealt with through phone calls, telexes, and informal meetings, without any legal basis for the defence of foreigners' rights.

From the municipal elections of 1983 onwards, the Front National gained political representation, and the politicisation of the issue of immigration continued to multiply the negative images of the phenomenon on subjects such as competition in the labour market, radical Islamism, and prayers in the public space. At the same time, non-European immigrants began to settle permanently in French territory, with return trips to their home countries no longer being possible due to the closure of the European Union's external borders. A security arsenal developed in Brussels, which accelerated the militarised vision of the subject of the immigrant and strongly distinguished Europeans from non-Europeans with increasingly dissuasive and repressive control instruments (Dublin agreements on asylum, visas, fingerprinting of asylum seekers, Frontex). The fall of the Iron Curtain added a new element to the theme of new competitors, such as the emblematic "Polish plumber", while terrorism, from 1995 onwards, gave credence to the supporters of the unbridgeable divide with Islam.

The last two decades have seen the globalisation of the phenomenon of migration, and a confrontation between the advocates of globalisation and cosmopolitanism and those who are turning back to their "roots", the "native French" and those who are not-in a country where 30% of the population has a foreign ancestor-against a backdrop of rising European populism. Numerous contradictions emerge: labour needs dictated by economic liberalism despite the loss of influence of employers over the last 30 years, a vision of security, an ethic of solidarity with refugees, and the offences of solidarity inflicted on those who welcome them. Contrasting images of the figure of the Other today oppose the treatment of Ukrainians and refugees from the Middle East or Africa, the latter being suspected of being "asylum cheats".

The stereotypes have always been the same throughout the different periods, whatever the successive waves of migration: violence, communitarianism, lack of integration, conservatism of lifestyles. Today, there is a confusion of terms between the migrant, who is undesirable, and the refugee, who cannot be totally rejected. There is also a hierarchy between the two, depending on their origins. Certain boundaries in collective representations have become more pronounced, such as the one between Europeans and non-Europeans, Muslims and Christians, but they are largely constructed and linked above all to the migratory regimes that are at the origin of undocumented migrants, unaccompanied minors, and rejected asylum seekers, rather than to the intrinsic characteristics of the migrants themselves, who are often lumped together and not considered individually in their diversity.

You have conceived this book as a research itinerary over the course of 40 years of work on immigration, and you take a certain distance from this Other, which has been your object of research over these four decades. In this book, you focus on images, on the imaginary, based not only on your numerous research projects, on the rich literature on this theme, but also on filmography. Can you tell us more about this?

Examining images and collective representations required me to take a different look at what I had studied, looking at representations of immigration as they appeared in the press, films, novels, televised political debates, public policies or by referring to the work of historians on images of the Other. No study had ever been carried out on this topic looking at such a large time span and by mixing such varied sources of data relating to the constructions of the Other: war of numbers, categorisations, preconceptions, national and European public policies, emblematic figures of the foreigner, the specialised worker, then the Muslim, the young people living in the suburbs, the terrorist, the refugee, the undocumented migrant, all of which are the objects of successive constructions and deconstructions in the course of the forms of depoliticisation and politicisation of the Other.

Different levels of analysis are questioned as shaping the framework, as well as the monographs collected in the survey work. Reconstructions also exist in this landscape, against the negative images: inclusive citizenship, the fight against discrimination, the construction of a memory of living together through the use of museums, because stereotypes are persistent before accepting that the Other resembles us in societies that are becoming increasingly cosmopolitan. The discrepancy between migration policies, which are often presented as a response to crises and are based on opinion polls, and the fear of those who are afraid often leads to the failure of these policies and to a headlong rush into the security arsenal. The figures of the Other reflect this state of affairs. Do the aesthetics of the migrant play a role? How do the images conveyed in our societies maintain a culture of fear of otherness, a source of rejection of those who embody immigration? Migration policies that are intended to be dissuasive end up creating the figure of the undesirable, by denying migrants access to housing, to the labour market, to rights, in a never-ending war on migrants, as can be seen in the Mediterranean. They have the opposite effect to that desired, because they do not dissuade the most determined to change their lives. They spread a negative image of young people who do not work, who wander in urban areas, who have come because of the appeal of Western societies. Today, the « push factor », that pushes people to leave their homes, is more powerful than the « pull factor ». Unlike in the past, what leads people to leave their country is linked to political crises, endemic unemployment, corruption of the leaders, and ambient instability. And those who leave are more educated, more qualified, and more urban than in the past, which no longer corresponds to the image of the rural and illiterate migrant, who left to earn money and send it back home with a view to returning. But representations still lag behind the very rapid evolution of the multiple transformations of the Other.

A study of institutional discrimination shows that representations of the Other can also lead to the intervention of public actors, where this Other is contextualised in relation to a territory, to a real or supposed group of belonging, in a determinism that is sometimes implacable: a study of young people of immigrant origin in the French army shows that they have difficulty being recognised by their fellow soldiers as French like the others, because they are suspected of being part of assigned communities...

Interview by Miriam Périer, CERI.

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Miriam Périer

CAUGHT IN THE NUCLEAR TRAP(S)? THE RESPONSIBILITY AND FINDINGS OF INDEPENDENT SCHOLARSHIP

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the 13,000 nuclear weapons involved would be enough to jeopardise global food supplies. That is why the accuracy of our knowledge on this subject is so crucial. But, as we will discuss later, the knowledge that is supposedly available is not supported by adequate evidence.

Regrettably, in the last 25 years, none of the top francophone academic journals have published so much as a single article on the possibility of nuclear war and its relation to political action. In France, the most substantial treatment of the subject can be found in philosophy not in political science, in the writings of Jean-Pierre Dupuy and in those of other readers of Günther Anders, such as Marc Crépon. I therefore consider the field of nuclear studies to be a transnational one, written mainly in English and known as "nuclear studies" or "nuclear security studies". In this field however, the effects of the nuclearization of the world on the possibility and forms of democratic government are hardly ever addressed. The only exceptions are the works of Elaine Scarry, Garry Wills and Avner Cohen, which are monographs on the American and Israeli cases. A robust comparative study has yet to be done, and this book intends to lay the groundwork for this, while awaiting Thomas Fraise's PhD dissertation, which deals directly with this subject. This is all the more important as studies on democracy operate as though nuclear weapons played no role and were compatible with democratic practices, without putting this assumption to the test. The three following examples show that accepted knowledge is not satisfactory.

First, drawing on the work of Paul Edwards and Daniel Deudney, 1 among others, I show that the satellite-based global surveillance infrastructure emerged from a primary injunction to detect all enemy nuclear weapons in order to target them, because even a single nuclear strike was deemed intolerable. Similarly, global monitoring also relies on seismic activity measuring devices to detect underground nuclear tests. In this way, nuclear weapons find a place in the discussion of democracy and surveillance.

Second, while some authors such as Colin Crouch have formulated the notion of post-democracy, it is striking that the factors he identifies do not include the nuclearization of the world. The third element that seems essential to me is that the nuclear state expects its citizens to consent to three commitments that certainly warrant further study. It expects them to consent to be a target: in a world governed by nuclear deterrence, the adversaries with large arsenals will target not only the centres of power but also most likely the French nuclear weapons in order to limit the damage they could inflict upon them in return. Citizens are also expected to consent to the fact that the head of state can use the arsenal on behalf of the whole political community, since the speed of ballistic missiles does not allow time for any consultation. Finally, they are expected to consent that their taxes will be used to finance this arsenal and its modernisation.

The French reader may find this surprising because he or she frequently hears that there is a consensus in France on this issue. The chapter on "creating a space for democratic choice by re-characterising the role of the expert" shows how this illusion was constructed, the methodological flaws that perpetuate it, and then tests it through two unpublished surveys whose robust results invalidate the consensus thesis. The archives also challenge the idea of a past consensus in the French citizenry that has eroded. This therefore opens an essential field of study that (re)connects democracy and the politics of nuclear weapons systems by questioning the impact of the nuclearization of the world on the possibility of democracy and democratic practices, rather than assuming that they are compatible and that the former has no effects on the latter. Do you consider that nuclear research (civil or military) can be done independently?

The work of the programme I am pleased and fortunate to have led for five years, since 2017, Nuclear Knowledges, proves that such research is possible and fruitful. To avoid unnecessary controversy, let me state from the outset that independent research is not a subjective label, but is recognised by verifiable practices. These include the nonappropriation of categories of official or activist discourse as categories of analysis, a full awareness of the effects of self-censorship linked to using the categories of nuclear thought, the firm stance of refusing any conflict of interest (which translates into exclusive funding on the basis of academic merit), and the building of an interdisciplinary research design. These four gestures make possible to raise the questions that were avoided by the supposed performativity of the official discourse and allow to independently reassess claims about the effects of particular policy choices. On the issue of nuclear energy, we have had the pleasure of funding, in the framework of the ANR VULPAN project, Valerie Arnhold's research on the normalisation of nuclear accidents by different organisations that construct them as conceivable and surmountable.

By choosing financial independence and interdisciplinarity, it becomes possible to identify the mismatches between accepted knowledge and available evidence and to try to remedy them.

Let me give you four examples, which are key findings of the book.

We have already mentioned the frequently repeated assertion of a French consensus on the policy of nuclear deterrence-which indeed exists at the level of political parties. It is worth noting that the official surveys on which this claim is based, issued by the communication unit of the Ministry of the Armed Forces, frame the questions as though the main assumptions of the official discourse were established truths (nuclear weapons being associated with deterrence, a strictly defensive and risk-free posture) and reproduce the basic shape of its communication strategy, i.e., no mention of the costs or possible undesirable effects. Avoiding such biases, we can reformulate and ask the question of French attitudes towards nuclear weapons policies in a way that allows for a more diverse set of attitudes. We find that the only attitudes that are supported by more than 50% of the respondents reflect a feeling of illegitimacy of citizens taking part in such conversations and their apprehensiveness of the consequences that would result from even participating in such a discussion.

The second example of mismatch between accepted knowledge and available evidence, which became visible thanks to the efforts of independent and interdisciplinary research, concerns the credibility of the French nuclear deterrence. Leading French analysts measure it against French sources, which is obviously inadequate. We have therefore called upon an engineer and nuclear physicist to conduct an independent technical analysis of the performance of the first generation of the French strike force, and have conducted archival research in the United States, the United Kingdom, and on a series of Russian documents. These documents establish that, from the point of view of allies and potential adversaries, the French strike force was not perceived as a credible threat until at least 1974 and was not technically capable of accomplishing the objectives assigned to it. More research still needs to be conducted on when this credibility was achieved, based on appropriate sources rather than on the incantatory repetition of French leaders' and engineers' desire for credibility. This result is all the more important because the majority of the members of the Defence and Armed Forces Committee of the National Assembly, who were kind enough to answer my questions, believe that the French strike force became credible much earlier.

The third gap concerns French officials, experts, and media who all accept a framing of the nuclear weapons problem in terms of horizontal proliferation as if it were inevitable and thus restricted possibilities. However, a detailed study shows that the post-Cold War period is a period of historically low proliferation and that the nuclear-armed states, permanent members of the UN Security Council, have played an essential role in the spread of nuclear weapons. None of the current nuclear weapon states acquired its arsenal without the help of at least one of the P5. This is a far cry from the intrinsic desirability of nuclear weapons, wrongly assumed by what I call the "paradigm of proliferation", which hides the fact that the renunciation of nuclear weapons is more common than proliferation on any scale, and which also obscures the responsibility that nuclear-armed states have in this phenomenon. It is essential to critique this assumption of inevitability of proliferation because, as I have shown in my book, it is widely disseminated in the public opinion through the repeated claims of experts, journalists, and officials. Let me use the work of the talented cartographer Benoît Martin to illustrate this result. A fourth fundamental element about which conventional wisdom is not supported by adequate evidence is the role of luck in the fact that there have not been any unwanted nuclear explosions yet. This role of luck has been asserted by American, Russian, and British officials since the 1960s, but the literature does not take them seriously. In fact, the literature suggests either that the role of luck cannot be assessed and thus deduces, at the cost of an obvious methodological flaw, that it does not play a role (rejecting the counterfactual method leads to such an error); or it claims that the non-relevance of luck can be proven because what matters is control. The book thus proposes a method for assessing this role of luck (defined as three modes irreducible to control) and a typology of the modes by which it is denied. It also uses American and British archives to show that luck has been essential in avoiding unwanted nuclear explosions so far.

Finally, it proved possible to problematise the practices by which official categories and the assumptions of the paradigm of proliferation are appropriated. We also problematise the irresponsibility of para-official experts, offer categories that make it possible to go beyond the framework of the proliferation paradigm (vulnerabilities, renunciation, chance) and to assess the validity of the assumptions at work. Thus evaluation replaces incantation.

Once the elements that underpin the inevitability of the current policy have been invalidated-the inevitability of proliferation, perfect control over weapons and no role for luck, consensus in the French population, and allegedly adequate expertise-I show, in the concluding chapter of the book, what kind of justifications would be consistent with the current policy. They turn out to be very different from the official justifications.

I would also like to mention another important study conducted by the team, one that is emblematic of my point about financial independence coupled with interdisciplinary work making new research questions possible. Dr. Sébastien Philippe, a researcher associated with the programme, combined a novel analysis of declassified archives with new computer modelling to re-evaluate the consequences of the French tests in Polynesia, which had previously been substantively underestimated.

Does this independence distinguish researchers from experts?

In fact, it shows why we cannot expect para-official experts to provide a complete overview of nuclear vulnerabilities, particularly because of the discursive requirements of deterrence. The experts who place themselves at the service of the state are trapped in a double bind.

First, while deterrence is based on the acceptance of a primary material vulnerability, the official discourse adopts the rhetoric of protection and conceals that underlying vulnerability. Le Redoutable Submarine, Cité de la Mer, Cherbourg, France. Photo by Miriam Périer, April 2022. Then, a second limitation amplifies the first one: the discourse of deterrence plays both a descriptive and a performative role. It aims to describe international power relations, but it is also reaffirmed and repeated to make deterrence more credible. As a result, official and para-official experts cannot say that its failure is possible and that a nuclear war would follow. Replacing the reality of vulnerability with a rhetoric of protection makes this eventuality inconceivable. Therefore, to believe in the official or expert discourse on vulnerabilities is to be mistaken about its nature, which is assumed to be merely descriptive.

Equally serious is the overconfident belief that nuclear war or unwanted explosions are impossible. The book shows the other means by which these experts wrongly convince themselves that a nuclear disaster is impossible.

The independent scholar always keeps in mind that our knowledge on the nuclear past depends upon the availability of primary sources, that most nuclear weapons states are not transparent on it, and this has consequences. The United States and the United Kingdom have been exceptions. So, an important part of our work is to understand the epistemic and political consequences of this limited universe of data, the shape of which is decided by states, to try to extend it, to diversify sources and to show the consequences of a discourse which would consider the existing universe of data as complete. One implication is that what I was saying earlier about the role of luck is most likely an underestimation. Treating it as a complete assessment would require accepting that Russia, France, China, Israel, India, Pakistan and North Korea have been capable of a perfect control over their nuclear arsenals while the declassification of US and UK archives has uncovered several cases of luck in these two countries alone.

What is the cost of an independent research like yours?

The results of the work of a relatively small team of a dozen researchers over five years in total demonstrate the exorbitant cost of research that is not independent. Citizens, whether elected or not, civilians or military, and the scientific community have been paying this price as they were relying on incomplete or inexact knowledge as discussed above. The results obtained by my team about the inadequacy of accepted knowledge and available evidence could and should have been obtained a long time ago. By funding research that suffers from conflicts of interests and/or accepts the categories used by official actors as analytical categories, we produce an incantatory discourse and the illusion that the progress of knowledge is impossible and superfluous. Such an approach perpetuates the irresponsibility of experts who commit serious methodological flaws, and maintains the impossibility of political responsibility, since no alternative is proposed to representatives and citizens beyond a binary between status quo and chaos and the continuation of current policies is justified by this lack of alternative. In a democracy, this would be an unacceptable state of affairs. In a country that intends to be at the cutting edge of knowledge, it would also be unacceptable, since numerous studies have already shown how conflicts of interest in research funding have produced considerable distortions in results, in fields as varied as energy policy, the effects of tobacco on health, and the production of information. We assume, strangely enough, that this would not be the case in the field of nuclear studies. Faced with a trend of increasing precariousness in public universities and the increasing reliance on external funding, particularly military funding, we must refuse both precariousness and the subordination of research to conflicts of interest. Let us not fall into the trap of accepting conflicts of interest as the only alternative to job insecurity.

The programme's appeal to young researchers is further proof of the fruitfulness of this intransigence on independence and interdisciplinarity. We have welcomed many doctoral students from prestigious universities such as Brown and Cornell. Several promising scholars have expressed desire to join our program. Two of them have been awarded a Marie Curie grant.

In the same vein, you write in your book: "It is high time that a prudent and independent moderator makes a public debate possible, based on clear statements and alternatives, which he or she will confront with their possible contradictions, with new research results and with the extent of what remains to be discovered". Do you think that a researcher, an intellectual, should play the role of a "diplomat", a mediating authority in the nuclear field?

The purpose of independent research, as opposed to pro-or antinuclear activists, is to offer the possibility of a clear and coherently justified political choice. The aim is to accurately question the memories of the past, the visions of the future, and the values in the name of which it is claimed that our political community should adopt this or that policy. Let us not hide these choices behind unwarranted claims of inevitabilities. Therefore, the book finishes with the proposal to desacralize nuclear choices without conventionalising them. We must be able to ask fundamental questions clearly and explicitly: which weapons systems for which defence policies for the nation and for Europe? Grounded in which imagined future? Let us bear in mind that according to the French Minister of the Armed Forces, Florence Parly, these policies are binding until 2090.

One of the central methodological propositions of the book and of the work I have been conducting in parallel is to show the constitutive role of imagined futures in determining the scope of nuclear possibilities. As the concluding chapter shows, there are imaginable futures in which nuclear weapons are necessary for us, others in which they have little relevance, others in which they are harmful to those who possess them (if hacking them becomes possible for instance), and others in which we can use other means to accomplish our goals. In our thinking about future enemies that cannot be deterred with nuclear weapons, we should incorporate non-nuclear existential challenges such as climate change and biodiversity collapse. Indeed, claims of 'success of nuclear deterrence' are predicated on the idea that the country on behalf of which such claims are made is still inhabitable. Those who have already made their choices should be able to debate them. The independent researcher serves the debate but has a demanding idea of it. Debate is not merely confrontation between existing preconceptions, but discussion of coherent positions based on the most recent advances in knowledge. The researcher must be sure to avoid rhetorical illusions of inevitability, of the insignificance of imagined futures that do not need to be discussed, or of contradictions. The independent researcher thus enables a democratic debate between different clearly justified alternatives.

If I may, I would like to end by paying tribute to two French authors with very different profiles, Bastien Irondelle and Georges Le Guelte. In spite of their differences, they share the same integrity and intellectual generosity, they have both used the tools of political science, and have both been mentors and inspirations for me. It is this tradition of honest, independent, and ambitious research in the service of the possibility of democratic debate that I invite our readers to nourish.

Interview by Miriam Périer, CERI.

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Alexis Guedon

Sébastien Riviere

Fabrice Carrat

Thibault Mahevas

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A Mekinian

Arsène Mekinian

Arsene Mekinian
email: arsene.mekinian@aphp.fr

Survenue de cancers au cours de la sclérodermie systémique : facteurs de risque, impact sur la survie et revue de la littérature

Keywords: sclérodermie, cancer, néoplasie, anticorps anti-Scl70, crise rénale sclérodermique, systemic sclerosis, cancer, autoantibodies, renal scleroderma crisis

Introduction

Les patients atteints de sclérodermie systémique ont un risque plus élevé de cancer que la population générale.

Dans cette étude, nous avons analysé la survenue de cancers chez ces patients, les risques associés et l'impact sur la survie globale.

Patients et Méthodes

Dans une cohorte monocentrique de patients suivis de janvier 2004 à décembre 2017, nous avons recueilli les caractéristiques cliniques (survenue de cancer, exposition toxique, atteinte d'organe), biologiques et les traitements utilisés.

Résultats

Deux-cent dix patients étaient inclus, et 21 patients (10%) ont développé un cancer solide au cours du suivi.

Parmi ceux-ci, on notait des adénocarcinomes du sein (n=6, 28%), des cancers broncho-pulmonaires (n=6, 28%), digestifs (un adénocarcinome du sigmoïde, une tumeur carcinoïde de l'appendice), ovarien et du col utérin (n=1 de chaque cas), un mélanome, un carcinome rénal à cellules claires et un cancer papillaire de la thyroïde. Le délai médian entre l'inclusion et le diagnostic de cancer était de 4 [START_REF] Olesen | Systemic sclerosis and the risk of cancer: a nationwide populationbased cohort study[END_REF][START_REF] Colaci | Breast cancer in systemic sclerosis: results of a cross-linkage of an Italian Rheumatologic Center and a population-based Cancer Registry and review of the literature[END_REF][START_REF] Zhang | The risk of cancer development in systemic sclerosis: a meta-analysis[END_REF][START_REF] Joseph | Association of the autoimmune disease scleroderma with an immunologic response to cancer[END_REF][START_REF] Moinzadeh | Association of anti-RNA polymerase III autoantibodies and cancer in scleroderma[END_REF][START_REF] Hoogen F Van Den | classification criteria for systemic sclerosis: an American college of rheumatology/European league against rheumatism collaborative initiative[END_REF][START_REF] Bernal-Bello | Novel risk factors related to cancer in scleroderma[END_REF][START_REF] Lazzaroni | Malignancies in Patients with Anti-RNA Polymerase III Antibodies and Systemic Sclerosis: Analysis of the EULAR Scleroderma Trials and Research Cohort and Possible Recommendations for Screening[END_REF][START_REF] Onishi | Cancer incidence in systemic sclerosis: meta-analysis of populationbased cohort studies[END_REF] ans. La survenue de cancer n'était pas associée à une surmortalité avec une médiane de survie au premier quartile (75%) de 12 ans chez les patients ayant développé un cancer et de 11.6 ans en absence de cancer associé (p = 0,9). L'antécédent de crise rénale sclérodermique (HR 10.99, IC95% [1,95 -62,07]; p=0,006) et la présence d'anticorps anti-Scl70 (HR 5,5, IC95% [1,40 -21,67]; p=0.01) étaient significativement associés avec la survenue d'une néoplasie, alors que la présence d'un reflux gastro-oesophagien était inversement corrélée (HR 0,22, IC95% [0,056 -0,867]; p=0,03).

Conclusion

La survenue d'une crise rénale sclérodermique et la positivité des anticorps anti-Scl70 étaient associées à la survenue d'une néoplasie chez les patients suivis pour une sclérodermie systémique dans cette étude monocentrique.

Mots clés: sclérodermie, cancer, néoplasie, anticorps anti-Scl70, crise rénale sclérodermique.

Introduction

La sclérodermie systémique est une affection auto-immune chronique altérant le tissu conjonctif et les microvaisseaux. Elle est responsable d'anomalies de la microcirculation et d'une fibrose cutanée pouvant toucher d'autres organes [START_REF] Abraham | Overview of pathogenesis of systemic sclerosis[END_REF].

Les patients atteints de sclérodermie systémique ont un risque de cancer plus élevé que la population générale [START_REF] Olesen | Systemic sclerosis and the risk of cancer: a nationwide populationbased cohort study[END_REF]. Ce risque concernerait en particulier les cancers solides broncho-pulmonaires et du sein [START_REF] Colaci | Breast cancer in systemic sclerosis: results of a cross-linkage of an Italian Rheumatologic Center and a population-based Cancer Registry and review of the literature[END_REF], ainsi que les hémopathies malignes (4).

Les mécanismes physiopathologiques responsables de l'augmentation de la prévalence des néoplasies dans cette population sont multiples. Des facteurs génétiques (5), environnementaux et immunologiques, en particulier la présence d'anticorps anti-ARN polymérase III (6) ont été décrits. La fibrose atteignant les différents organes pourrait également favoriser l'oncogenèse [START_REF] Zhang | The risk of cancer development in systemic sclerosis: a meta-analysis[END_REF]. Enfin, certains traitements immunosuppresseurs utilisés dans la sclérodermie systémique peuvent être impliqués, comme par exemple le cyclophosphamide [START_REF] Schottenfeld | Chronic inflammation: a common and important factor in the pathogenesis of neoplasia[END_REF]. Bien que plusieurs études aient soulevé ce risque de cancer associé, les données prospectives à long terme restent peu nombreuses, de même que l'impact des différents cancers sur la survie.

Dans cette étude incluant une cohorte monocentrique prospective, la survenue de néoplasies chez les patients atteints de sclérodermie systémique a été analysée, ainsi que les risques associés et l'impact sur la survie.

Méthodes

Patients

Tous les patients suivis dans le service de médecine interne de l'hôpital Saint-Antoine pour une sclérodermie systémique, définie selon les critères de l'«American College of Rheumatology -European League Against Rheumatism», étaient inclus de Janvier 2004 à Décembre 2017 [START_REF] Hoogen F Van Den | classification criteria for systemic sclerosis: an American college of rheumatology/European league against rheumatism collaborative initiative[END_REF].

Les caractéristiques recueillies comportaient le tabagisme, la prise de toxiques et d'alcool, les antécédents personnels et familiaux de cancers, les expositions professionnelles, le type de sclérodermie systémique, le début de la maladie (définie à partir du premier symptôme non-Raynaud), les organes atteints, le score de Rodnan, les données des épreuves fonctionnelles respiratoires (EFR) et de l'échographie cardiaque transthoracique. Les valeurs de la protéine C-réactive (CRP), du bilan hépatique et rénal, du bilan immunologique ont été recueillies, telle que la présence d'autoanticorps antinucléaires, des anticorps anti-Scl70, anti-centromères, anti-ARN Pol III et anti-RNP. Les traitements utilisés, la dose de prednisone, le type de traitement immunosuppresseur et la durée, la prise d'antiagrégants plaquettaires et d'inhibiteurs de la pompe à protons ont été également recueillis.

Analyses statistiques

Les données étaient exprimées en médianes avec les valeurs extrêmes, ainsi qu'en nombre avec leur fréquence.

Le test de t-Student ou Mann Whitney étaient utilisés pour comparer les variables continues et le test chi-square ou Fischer exact pour les variables qualitatives selon la distribution. L'analyse de survie était exprimée par les courbes de Kaplan Meier et menée avec le test de log-rank permettant de comparer les différents groupes. Le modèle de Cox « pas à pas » était utilisé pour déterminer les caractéristiques significatives en analyse univariée, puis le modèle de régression de Cox pour l'analyse multivariée, afin de détecter les variables indépendamment associées à la survenue d'une néoplasie.

Résultats

Deux-cent dix patients suivis pour une sclérodermie systémique étaient inclus, dont 189 femmes (90%), avec un âge moyen au diagnostic de 48.7±5 ans. La sclérodermie systémique était de forme cutanée limitée chez 137 (66%) et diffuse chez 72 patients (34%). Les caractéristiques générales des patients sont présentées dans le Tableau 1. Au cours du suivi médian de 72.5 mois [1 -160], 21 patients (10%) ont développé un cancer solide dont 17 femmes (81%), avec un délai médian de survenue de 4 [START_REF] Olesen | Systemic sclerosis and the risk of cancer: a nationwide populationbased cohort study[END_REF][START_REF] Colaci | Breast cancer in systemic sclerosis: results of a cross-linkage of an Italian Rheumatologic Center and a population-based Cancer Registry and review of the literature[END_REF][START_REF] Zhang | The risk of cancer development in systemic sclerosis: a meta-analysis[END_REF][START_REF] Joseph | Association of the autoimmune disease scleroderma with an immunologic response to cancer[END_REF][START_REF] Moinzadeh | Association of anti-RNA polymerase III autoantibodies and cancer in scleroderma[END_REF][START_REF] Hoogen F Van Den | classification criteria for systemic sclerosis: an American college of rheumatology/European league against rheumatism collaborative initiative[END_REF][START_REF] Bernal-Bello | Novel risk factors related to cancer in scleroderma[END_REF][START_REF] Lazzaroni | Malignancies in Patients with Anti-RNA Polymerase III Antibodies and Systemic Sclerosis: Analysis of the EULAR Scleroderma Trials and Research Cohort and Possible Recommendations for Screening[END_REF][START_REF] Onishi | Cancer incidence in systemic sclerosis: meta-analysis of populationbased cohort studies[END_REF] ans après le diagnostic de sclérodermie.

Les cancers étaient des adénocarcinomes du sein (n=6, 28%), des cancers broncho-pulmonaires (n=6, 28%), des cancers digestifs (adénocarcinome du sigmoïde=1, une tumeur carcinoïde de l'appendice=1), un cancer ovarien et du col utérin, un mélanome, un carcinome rénal à cellules claires, un cancer papillaire de la thyroïde et deux néoplasies d'origine indéterminée. On relevait un tabagisme chez seulement deux des 6 patients ayant présenté un cancer broncho-pulmonaire.

La comparaison des caractéristiques des patients ne montrait aucune différence significative en considérant l'âge, le sexe, les atteintes d'organes, le score de Rodnan, le tabagisme, l'exposition professionnelle, les facteurs de risques cardiovasculaires, les traitements immunosuppresseurs, la prise d'inhibiteurs de pompe à protons ou d'aspirine (Tableau 1). Aucune myosite paranéoplasique associée à la sclérodermie n'était diagnostiquée au cours du suivi.

Au cours du suivi de 72,5 mois [1 -160], on observait 31 décès (15%) dont 5 cas en rapport avec la néoplasie (16%). La médiane de survie n'était pas significativement différente chez les patients avec et sans cancer au cours du suivi, avec une médiane au premier quartile (75%) de 12 ans en cas de cancer associé et de 11.6 ans en absence de cancer (p = 0,9) (Figure 1).

Discussion

Dans cette étude observationnelle monocentrique, la survenue de cancers au cours de la sclérodermie systémique et les facteurs associés et la survie globale étaient analysés. Les nombreuses données de la littérature concluent à un risque majoré de néoplasie au cours de la sclérodermie systémique et dix pourcents des patients ont développé un cancer au cours du suivi médian de 6 ans dans cette série (4, 10) (Tableau 2). La prévalence globale de cancer sur cinq ans dans la population générale française n'était que de 2% en 2018 (32). Cette prévalence était également élevée dans d'autres cohortes de patients atteints de sclérodermie systémique, notamment à 12% dans celle de Bernal-Bello [START_REF] Bernal-Bello | Novel risk factors related to cancer in scleroderma[END_REF].

Les cancers du sein (28%) et broncho-pulmonaires (28%) sont les cancers les plus fréquents. Ces résultats sont concordants avec leur incidence respective dans la population générale. Le cancer du sein est en effet le plus fréquent chez la femme en France (incidence 28.6% en 2018) et le cancer du poumon le deuxième tous sexes confondus (incidence 12.3% en 2018) (32). Le cancer du côlon n'était en revanche que très peu représenté et aucune hémopathie maligne n'a été mise en évidence dans cette cohorte.

La sclérodermie systémique peut s'associer à différents types de néoplasies. Une augmentation statistiquement significative de cancers du poumon et de lymphomes non-hodgkiniens était mise en évidence dans la métaanalyse de Zhang et al [START_REF] Zhang | The risk of cancer development in systemic sclerosis: a meta-analysis[END_REF]. A ceux-ci, s'ajoutaient les cancers du foie et de vessie dans celle d'Onishi et al [START_REF] Onishi | Cancer incidence in systemic sclerosis: meta-analysis of populationbased cohort studies[END_REF].

En revanche, aucune des deux méta-analyses ne montrait d'association avec le cancer du sein (4, 10), alors qu'il était majoritaire dans la cohorte anglaise avec 42.2% de cancer du sein contre 10% de cancers bronchopulmonaires (6) (Tableau 2).

La présence d'anticorps anti-Scl70 et un antécédent de crise rénale sclérodermique étaient significativement associés à la survenue de cancer dans cette étude. Les fréquences et le type de cancers, ainsi que les facteurs de risque identifiés des principales séries de la littérature sont représentés dans le Tableau 2. La positivité des anticorps anti-Scl 70 avait déjà été mise en évidence en association aux néoplasies pulmonaires dans une cohorte italienne [START_REF] Colaci | Lung cancer in scleroderma: results from an Italian rheumatologic center and review of the literature[END_REF]. Il s'agit d'anticorps retrouvés chez 40% des sclérodermies, dirigés contre la topoisomérase I, une enzyme capable de générer des réarrangements de la structure de l'ADN. Ils sont classiquement associés aux formes diffuses de sclérodermie et à un moins bon pronostic [START_REF] Hamaguchi | Autoantibody profiles in systemic sclerosis: Predictive value for clinical evaluation and prognosis[END_REF]. La crise rénale sclérodermique serait plus fréquemment associée aux sclérodermies cutanées diffuses et aux anticorps anti-Scl 70 [START_REF] Gonzalez | Autoantibody profile in progressive systemic sclerosis as markers for esophageal involvement[END_REF]. Le lien direct avec l'oncogénèse reste difficile à déterminer.

Aucun traitement n'était identifié comme facteur favorisant de cancer dans cette cohorte. Le cyclophosphamide oral utilisé au cours de la sclérodermie systémique était associé à une incidence plus élevée de carcinomes épidermoïdes cutanés, d'angiosarcomes et de carcinomes urothéliaux in situ dans certaines études précédentes [START_REF] Tashkin | Cyclophosphamide versus placebo in scleroderma lung disease[END_REF]. Le nombre faible de patients traités par cyclophosphamide, ainsi qu'un traitement majoritairement par voie intraveineuse pourrait expliquer l'absence d'association significative dans cette étude.

Quant au reflux gastro-oesophagien, il semblait être un facteur protecteur. Certaines cohortes l'associent aux formes cutanées limitées de meilleur pronostic [START_REF] Gonzalez | Autoantibody profile in progressive systemic sclerosis as markers for esophageal involvement[END_REF] et les sclérodermies cutanées limitées étaient associées à une diminution du risque de développement de cancer de 30% lorsqu'elles étaient associées aux anticorps anticentromères dans la cohorte d'Igusa et al [START_REF] Igusa | Autoantibodies and scleroderma phenotype define subgroups at high-risk and low-risk for cancer[END_REF].

Malgré les nombreuses données de la littérature, l'identification de facteurs de risque semble difficile en raison de l'hétérogénéité des néoplasies identifiées. Par ailleurs, en absence de score d'activité facile à utiliser en routine il est difficile de déterminer si le risque de cancer est associé à une maladie active et progressive, à l'image de ce qu'on observe au cours de la polyarthrite rhumatoïde. Crise rénale sclérodermique (n; %)

Anticorps anti-centromere (n; %)

Anticorps anti-SCL70 (n; %) anti-ARN pol III (n; %) 71 (

Connectivites associées / myosites (n; %) 34 (16.2) / 5 (2.4) 4 (19) / 1 (0.5) 30 (15.9) / 4 (2.1)

Traitements reçus

Corticoïdes (n; %) 39 (18.6) 5 (14.3) 32 (16.9) Cyclophosphamide (n; %)

Mycophénolate mofétil (n; %) 6 (2.9) 1 (2.9) 5 (2.7)

Rituximab (n; %) 2 (0,9) 0 (0) 2 (1.1) IgIv (n; %) 2 (0,9) 0 (0) 2 (1.1) Aspirine (n; %) 21 (10) 2 (5.7) 18 (9.5)
Sildénafil / Bosentan (n; %) 1 (0.5)/ 6 (2.9) 0 (0)/ 0 (0) 1 (0. 25) sein [START_REF] Bonifazi | Systemic sclerosis (scleroderma) and cancer risk: systematic review and meta-analysis of observational studies[END_REF], poumon [START_REF] Onishi | Cancer incidence in systemic sclerosis: meta-analysis of populationbased cohort studies[END_REF], hémopathie [START_REF] Lazzaroni | Malignancies in Patients with Anti-RNA Polymerase III Antibodies and Systemic Sclerosis: Analysis of the EULAR Scleroderma Trials and Research Cohort and Possible Recommendations for Screening[END_REF], cancer cutané [START_REF] Hoogen F Van Den | classification criteria for systemic sclerosis: an American college of rheumatology/European league against rheumatism collaborative initiative[END_REF], thyroïde (4), endomètre (3), métastase sans primitif (3), gastroduodénal (2), ovaire (1), colon (1), rénal (1), pheochromocytome

Anti-PMScl (OR 3.13; IC 95% [1.18-8.62

L

  'analyse univariée puis multivariée permettait de mettre en évidence une association significative entre l'antécédent de crise rénale sclérodermique (HR 10,99, IC95% [1,95 -62,07]; p=0,006) ou la présence d'anticorps anti-Scl70 (HR 5,5, IC95% [1,40 -21,67] ; p=0,01) avec la survenue d'un cancer. La présence d'un reflux gastro-oesophagien était inversement corrélée à la survenue d'un cancer (HR 0,22, IC95% [0,056 -0,867] ; p=0,03).

1 .Tableau 2 .

 12 Dans cette étude, la présence d'un cancer n'était pas associée à une augmentation de la mortalité. Ces résultats doivent être interprétés avec prudence devant un faible nombre de cancers et des localisations multiples. La surveillance régulière et le dépistage précoce pourraient également être responsables d'une diminution de la surmortalité. Au contraire, le risque de décès était augmenté dans la cohorte espagnole de Bernal-Bello et al. La mortalité par néoplasies dans cette population était évaluée à 9% selon le registre de l'«European Scleroderma Trials and Research ». Notre étude comporte des limites, notamment son caractère rétrospectif, monocentrique et un effectif limité rendant les résultats difficiles à extrapoler. De plus, l'analyse concerne des néoplasies diverses avec un délai d'apparition pouvant aller jusqu'à plus de dix ans après le diagnostic de sclérodermie systémique. Bien que certaines données de la littérature convergent avec les résultats de cette étude, des études prospectives de plus grande ampleur sont nécessaires pour étayer ces résultats. Conclusion Dans cette cohorte, l'antécédent d'une crise rénale sclérodermique et la positivité des anticorps anti-Scl70 étaient associés à la survenue d'une néoplasie chez les patients suivis pour une sclérodermie systémique. Les néoplasies regroupaient en majorité les cancers broncho-pulmonaires et les cancers du sein. Conflits d'intérêt : aucun en rapport avec ce travail. Titre des Tableaux et Figures Tableau Caractéristiques des patients avec et sans néoplasie associée. Cancers au cours de la sclérodermie systémique : données de la littérature.

Figure 1 .Tableau 1 .

 11 Figure 1. Survie globale des patients avec sclérodermie systémique avec et sans néoplasie associée.

Cancers au cours de la sclérodermie systémique : données de la littérature.

	Auteur/ Année	N patients / N	Age /	Sclérodermie	Sclérodermie		Type de cancer	Facteurs de risque	Facteurs protecteurs
		cancers (%)	Sexe Féminin	diffuse	diffuse avec
			(%)		cancer (%)
	Igusa	2383 / 205 (9)	-/ (83)	913 (38)	77 (38)	sein (70), poumon (30), hémopathies, mélanome,	SSc diffuse avec ARN Pol III	SSc limitée (SIR 0.70, IC 95%
	2018					prostate, colorectal, ovaire, langue, rein	(SIR 2.05, IC 95% [1.44 -2.84])	[0.59 -0.84]), anti-centromères
	(Etats Unis)								(SIR 0.59, IC 95% [0.44-0.77])
	[28]
	Sargin	153 / 7	56.3/ 129 (84)	77 (50)	5 (71)	poumon (1), tractus gastro-intestinal (adénocarcinome	Aucun	Aucun
	2018	(5)				gastrique et tumeur neuroendocrine) (2), Syndrome
	(Turquie)					myélodysplasique (1), mélanome (2)
	[16]
	Bernal-Bello	432 / 53 (12)	-/	92 (21)	13 (
	2017		383 (89)
	(Espagne)
	[8]
							5)/ 5 (2.7)
		Statine (n; %)			6 (2.86)	0 (0)	6 (3.2)
		IPP (n; %)			130 (61.9)	15 (42.9)	109 (57.7)
		Décès (n; %)			31 (14.8)	4 (11.4)	22 (11.6)
		Suivi (mois)		72,5 [1 -160]	78.5 [12 -160]	74 [3 -149]
	SSc, Sclérodermie systémique ; RGO, reflux gastro-oesophagien ; PID, pneumopathie infiltrante diffuse ; HTAP,
	hypertension artérielle pulmonaire ; BNP, Brain natriuretic peptide ; CVF, capacité vitale fonctionnelle ; DLCO, capacité de
	transfert de l'oxyde de carbone ; CRP, protéine C réactive ; IgIv, immunoglobulines intraveineuses ; IPP, inhibiteur de
	pompe à protons.

*p<0.05 entre les patients avec et sans cancer associé.

Tableau 2.

  SSc : sclérodermie systémique; SIR : Standardized Incidence Ratio ; MM : myélome multiple ; LNH : lymphome non-hodgkinien ; LMC : leucémie myéloïde chronique ; CVF : capacité vitale fonctionnelle ; ORL : oto-rhino-laryngologique ; RGO : reflux gastro-oesophagien.

	Moinzadeh Kuo	2177 / 154 (7) 2053 / 83 (4)	-/ 1794 -/ 1581	710 (33) -	53 (34) -	sein (65), poumon (16), hémopathie (19), gastro-poumons (21), sein (11), langue (11), tube digestif	Anti-ARN pol III -		Aucun -
	2014 2012		(82) (77)			intestinal (17), génito-urinaire (6), gynécologique (9), hémopathies (7), col utérin (4), autres (20)	(HR 2.96, IC 95% [1.85 -4.73];
	(Angleterre) (Taiwan)					(17), cutané (6)	P < 0.001), âge avancé (HR
	[6] [22]						1.46, IC 95% [1.28 -1.67])
	Colaci Olesen	318 / 12 (4) 2040 / 222	51.5 ± -/ 1586	40 (13) -	0 -	cancers du sein poumon (29), sein (26), hémopathies (18),	Aucun Sexe masculin		Aucun Aucun
	2014 2010	(11)	14.5 / 287 (78)			gynécologiques, prostate, oesophage, pancréas,
	(Italie) (Danemark)		(90)			colorectal, rein, vessie, cutané, col utérin
	[3] [2]
	Zhang Chatterjee	7183 / -538 / 45	--/ 436	-187 (35)	-10 (22)	poumon, LNH, hémopathies, pas d'élévation poumon (10), sein (9), prostate (3), col utérin (3), foie	Sexe masculin Aucun		Aucun Aucun
	2013 2005	(8)	(81)			significative du risque de cancer du sein (3), Hodgkin (2), MM (2), thyroïde (2), cérébral (1),
	Méta analyse (Etats Unis)					rein (1), vessie (1), oesophage (1), estomac (1)
	[4] [23]
	Onishi Hill	6641 / -441 / 84	54 / 5266 57,6 / 363	20.0-34.8% 88 (20)	-10 (12)	poumon, foie, vessie, hémopathies poumon (12), sein (8), mélanome (5), prostate (3),	Sexe masculin SSc diffuse (SIR 2.73; IC 95%	Aucune Aucun
	[10] [24] Méta analyse (Australie) 2013 2003	(19)	(79) (82)			ovaire (1), rein (1), thyroïde (1) oesophage (1), estomac (1), foie (1), pancréas (1), vessie (3), rectal (2), hémopathies (2), ORL (2),	[1.31 -5.02])	])	(OR 0.48, IC 95% [0.25-0.94]) Aspirine
	Bonifazi Higuchi	7167 / 524 (7) 43 / 7	--/ 31 (72)	--	--	poumon, hémopathies poumons (2), gastrique (2), colon (1), utérus (1), foie	Aucun Anti-centromères		Aucun Aucun
	2013 2000	(16)				(1)	(Chi2 = 8.482,
	Kaşifoğlu 2016 [15] [25] Méta analyse (Japon)	340 / 25 (7)	49±11 / 314 (92)	165 (49)	16 (64)	vessie (4), sein (3), poumon non à petite cellule (3), hémopathies (MM, LNH, LMC) (3), col de l'utérus (2),	Aucun p < 0.05).		Aucun
	(Turquie) [17] [21] [26] (Italie) (Canada) 2013 1993 Colaci Abu Shakra	(7) 318 / 16 (5) 248 / 18	287(90) 51.4±14 / -/210 (85)	-99 (40)	-9 (50)	ovaire (2), endomètre (2), cutané (1), adénocarcinome estomac (1) (1), glioblastome (1), sarcome du tissu mou (1), de la thyroïde (1), colon (1), tumeur neuroendocrine prostate (1), mélanome (1), testicule (1) d'origine indéterminée (1), larynx (1), cancer papillaire poumon poumon (7), sein (5), gynécologiques (2), ORL (1),	95% [2.2-20.7]) Diminution de CVF (OR 6.7, IC [1.7-24.1]; p=0.006) Anti-Scl70 (OR 6.4, IC 95% Age avancé au diagnostic	Aucun Aucun
	Saigusa 2015 [18] [20] [27] (Japon) (Japon) (Etats Unis) 2012 1985 Hashimoto Roumm	261 / 17 (7) (4) 405 / 27 (7) 680 / 25	-/ 241 (92) (93) (77) -/ 376 50,1 / 202	-135 (33) -	-13 (48) -	métastase sans primitif connu (1) sein (1), colorectal (2), uretère (1), gastrique (2), col (1), syndrome myélodysplasique (1), médiastin (1), ovaire (1), fibrosarcome (1) utérin (1) colon (1), oesophage (1) utérus (1), Thyroïde (1), MM pancréas (1), ORL (2), mélanome (1), prostate (1), poumon (10), sein (4), gastrique (3), lymphome (2), poumon (9), sein (5), hémopathies (3), colon (2),	ARN Pol III 28%,) Aucun Fibrose pulmonaire (62% vs	Aucun Aucun Aucun
	Shah 2015 (Etats Unis) [19] Szekanecz Cette étude 2012 (Hongrie) [11] N : nombre ; 1044 / 168 (16) 218 / 10 (5) 210 / 21 (10)	-/ 863 (83) -31 / 189 (90)	385 (37) -81 (38)	68 (41) 5 (50) 19 (48)	-LNH (3), poumons (2), seins (2), leiomyosarcome (1), sein (6), poumon (6), tube digestif (2), gynécologiques (2), mélanome (1), rein (1), thyroïde (1) oesophage (1), col utérin (1), cutané non mélanome (1)	Age avancé au diagnostic Aucun Crise rénale sclérodermique (HR 10.99, IC95% 1.95 -62.07) (OR 1.04, IC 95% [1.02-1.05]), Anti-Scl70 peau blanche (OR 2.71, IC 95% (HR 5.5 IC95% 1.40 -21.67) [1.22-6.04])	RGO Aucun Aucun (HR 0.22, IC95% 0.056 -0.867)