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Cancer-associated fibroblasts (CAFs) act as key drivers of cancer progression and therapeutic resistance within the tumor microenvironment, but their diverse and context-dependent functions complicate therapeutic targeting. The limited clinical efficacy of CAF-targeting therapeutics has prompted a critical reassessment of CAF biology, therapeutic development, and emerging CAF-directed strategies. Unlike prior reviews that predominantly focused on CAF heterogeneity or isolated therapeutic modalities, this review systematically compares pharmacological and biologic CAF-targeting therapeutics, multifunctional nanomedicines, and biologically inspired and living platforms in terms of their underlying mechanisms of action and translational bottlenecks. Drawing on clinical evidence from CAF-targeting therapeutics, we identify several interconnected barriers to successful translation, including CAF heterogeneity and plasticity, patient-selection and biomarker limitations, preclinical-clinical mismatch and combination-treatment dependency, insufficient tumor penetration and systemic toxicity, and signaling redundancy and pathway compensation. Importantly, lessons from unsuccessful clinical trials are used to critically reassess whether current CAF-targeting nanomedicines and platforms adequately address these barriers. In parallel, we evaluate platform-specific translational challenges, particularly those related to biosafety and manufacturing feasibility. These analyses highlight the persistent gaps between the evolving understanding of CAF functional states, existing design rationales for nanomedicine and platforms, and real-world clinical practice. Future directions should therefore prioritize the identification of functionally defined CAF states, the optimization of clinically relevant models of advanced disease, and the development of therapeutic platforms tailored to clearly defined clinical needs. Finally, we propose an iterative translational roadmap and a hypothesis-generating sequential cancer cell/CAF dual-targeting framework to guide the development of clinically translatable CAF-directed therapies.