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Traditional cancer therapy has limitations due to a lack of specificity and efficiency in tumor-targeting, toxicity issues, and biological barriers, which affect the clinical efficacy of traditional agents as well as synthetically designed carriers. Exosomes have gained popularity as excellent biological carriers owing to their inherent biocompatibility, capability to overcome biological barriers, and ability to transport cargoes between cells naturally. This review discusses how engineering of exosomes, hybrid exosomes, and exosome mimics could be employed to deliver therapies, enhance tumor penetration, and enable multimodal treatment of cancers, including chemotherapy, gene therapy, immunotherapy, and theranostics. The biomimetic and hybrid platforms may overcome key limitations of native exosomes, particularly low production yield, heterogeneity, limited drug-loading efficiency, and scalability constraints, while preserving desirable biological functionality. Moreover, the review also emphasizes that the standardization in manufacturing, reproducibility in cargo, safety evaluation, and regulatory approval are the major obstacles to clinical application. Unlike many earlier reviews that were mainly centered on native exosomes, the current review discusses the engineering aspects of exosome-like nanoplatforms from a translational viewpoint.