The PI3K/AKT/mTOR signaling pathway is intimately involved in multiple facets of cancer biology, including the proliferation, differentiation, growth, apoptosis and migration of CAFs (16). PI3K consists of a regulatory subunit (p85) and a catalytic subunit (p110). Upon engagement with growth factor receptors such as EGFR, PI3K undergoes conformational changes that lead to the activation of Akt. Activated Akt subsequently phosphorylates downstream substrates, including apoptosis-related proteins Bad and Caspase-9, thereby modulating cellular processes such as proliferation, differentiation, apoptosis and migration. The mTOR, a key downstream effector of the PI3K/Akt pathway, is activated when Akt directly phosphorylates its Ser1448 residue. Activation of mTOR and its downstream signaling cascades regulates the translation of specific proteins essential for cell proliferation and transformation (17). The PI3K/AKT pathway has a critical role in CAF proliferation (Fig. 2), which is often driven by oxidative stress; a fundamental contributor to aberrant CAF expansion. Ataxia-telangiectasia mutated protein kinase, a pivotal redox sensor, is induced by PI3K/AKT pathway activation, thereby promoting the abnormal proliferation of breast CAFs (18). Furthermore, accumulating evidence indicates that the PI3K/AKT signaling axis facilitates the differentiation of various precursor cell types into CAFs. For instance, exosomes derived from gastric cancer cells induce the transdifferentiation of pericytes into CAFs via activation of the PI3K/AKT pathway (19). Additionally, hepatocellular carcinoma (HCC)-derived exosomal micro (mi) RNA-21 transforms hepatic stellate cells into CAFs through the Akt signaling pathway (20). Additionally, osteosarcoma cells stimulate the differentiation of mesenchymal stem cells into CAFs through Akt-dependent pathways, evidenced by increased expression of the CAF marker α-SMA (21). Given these roles, targeting components of the PI3K/AKT pathway represents a promising therapeutic strategy to inhibit the function of CAFs. Multiple studies have demonstrated that inhibitors targeting the PI3K/AKT/mTOR axis, whether administered alone or in combination with chemotherapeutic agents, effectively suppress CAF activity and consequently impede tumor progression (Table I) (22-35).

For example, the combination treatment of dovitinib with the PI3K/AKT/mTOR signaling inhibitors LY294002 or RAD001 resulted in additive inhibition of CAF invasion, demonstrating therapeutic activity against breast cancer metastasis (22). Rocuronium bromide, a non-depolarizing neuromuscular blocker, has been shown to inhibit the PI3K/AKT/mTOR signaling pathway, thereby blocking CAFs and attenuating esophageal cancer progression (23). Oxaliplatin, a classic third-generation platinum-based chemotherapeutic agent, inhibits xenograft tumor growth in mouse xenograft models by targeting the C-X-C chemokine motif receptor 3 (CXCR3)/PI3K/AKT axis secreted by CAFs (24).

The classic Chinese medicine formula Biejiajian pill has been found to inhibit HCC progression by suppressing PI3K and AKT phosphorylation in a mouse model of diethylnitrosamine/carbon tetrachloride-induced HCC (25). Inhibition of AKT phosphorylation is a key strategy to target CAFs. For instance, cisplatin, a commonly used anticancer drug, has been shown to reduce the ability of CAFs to promote lung cancer cell migration and invasion by inhibiting the AKT signaling pathway both in tumor cell models and in BALB/c nude mice tumor models (26). Cisplatin inadvertently induces CAFs to secrete plasminogen activator inhibitor-1 (PAI-1) and this paracrine cue fosters tumor progression while diminishing cisplatin response. Targeting PAI-1 with Tiplaxtinin inhibits AKT activation in CAFs and enhances cisplatin efficacy, producing in vitro and in vivo synergy (27).

Similarly, gold nanoparticles can enhance the effects of cisplatin by decreasing the density of CAFs through the Akt signaling pathway and reducing collagen I production in colorectal cancer (CRC) xenograft mice (28). Furthermore, the combination of camatinib and osimertinib markedly enhances tumor suppression and decreases CAF abundance in patient-derived xenograft models via AKT pathway inhibition in non-small cell lung cancer (NSCLC) (29). Mesalazine and the mTOR inhibitor everolimus, originally developed as immunosuppressants to prevent organ rejection, have recently been found to exert anti-proliferative effects on cholangiocarcinoma cells by blocking CAF-activated AKT signaling (30). Regorafenib, a multikinase inhibitor, has been shown to inhibit proliferation and induce apoptosis in CAFs in vitro, with its mechanism linked to the inhibition of AKT phosphorylation (31).

In NSCLC models, anlotinib was demonstrated to modulate the TME by inhibiting the AKT pathway and promoting CAF apoptosis, thereby enhancing therapeutic efficacy against NSCLC (32). Furthermore, bioactive compounds isolated from commonly consumed beverages exhibit CAF-inhibitory effects via AKT suppression. For instance, caffeine (1,3,7-trimethylxanthine), the most widely consumed psychoactive substance worldwide, inhibits CAF migration and invasion through phosphatase and tensin homolog-dependent inactivation of Akt and Erk1/2 signaling, effectively preventing breast tumor growth and recurrence in a safe manner (33). Dihydromyricetin, a flavonoid that is the main active ingredient in Garcinia cambogia, has been found to inhibit the proliferative potential of CAFs by targeting Akt activation (34). Additionally, researchers synthesized a drug targeting mTOR, tetracyclic heterocyclic azathiophenone MSI-N1014, which was able to inhibit the transformation of CAFs by decreasing mTOR expression, thus markedly reducing migratory ability, tumor-balloon generation and resistance to 5-fluorouracil (35).

In conclusion, current studies on regulating CAFs by inhibiting the PI3K/AKT/mTOR pathway primarily focus on suppressing the functions and activities of CAFs through this pathway. These include inhibiting CAF proliferation, promoting CAF apoptosis and reducing the secretion of pro-tumorigenic factors by CAFs. Most approaches utilize small molecule inhibitors or genetic interventions, indicating the critical role of the PI3K/AKT/mTOR signaling in modulating CAF activity. However, given the broad involvement of this pathway in diverse cellular processes, highly selective interventions targeting CAFs specifically are still lacking and treatment often carries significant systemic side effects. Overall, among the strategies targeting CAFs via the PI3K/AKT/mTOR pathway, the application of small molecule inhibitors is the most mature and has demonstrated considerable efficacy in suppressing CAF function. Nevertheless, these approaches predominantly focus on direct depletion or inactivation of CAFs, with relatively limited emphasis on stromal reprogramming. A subset of studies aiming for selective blockade of specific PI3K isoforms or downstream effectors has shown promising improvements in CAF selectivity, suggesting potential advantages. Furthermore, strategies that induce stromal remodeling through modulation of this pathway remain in the early stages of investigation; combining pathway inhibition with stromal reprogramming could yield more durable therapeutic outcomes in the future. In terms of clinical translation, most research remains at the preclinical stage, lacking comprehensive clinical validation and safety evaluation. Future efforts should prioritize the development of highly selective PI3K/AKT/mTOR modulators in conjunction with multimodal treatment strategies to optimize CAF-targeted therapies, ultimately achieving more effective antitumor responses with reduced off-target toxicity.

The JAK-STAT signaling pathway consists of three components: The tyrosine kinase-associated receptor that receives the signal, the tyrosine kinase JAK that transmits the signal and the transcription factor STAT that produces the effect. When various cytokines or growth factors bind to receptors, they phosphorylate and activate JAK. JAK then phosphorylates tyrosine residues on downstream target proteins and recruits and phosphorylates the transcription factor STAT (36). STAT forms dimers and enters the nucleus, where it binds to target genes and regulates their transcription. This process influences cell proliferation, differentiation and apoptosis (37). The JAK/STAT signaling pathway is constitutively activated in CAFs. For instance, CAFs can promote endometrial cancer growth by inducing the IL-6-activated STAT-3 pathway (38).

Similarly, in prostate cancer, CAF-derived IL-6 can attenuate p53 activity by activating the JAK/STAT signaling pathway, thereby protecting cancer cells from chemotherapy (39). Furthermore, in pancreatic ductal adenocarcinoma (PDAC), activation of the JAK/STAT signaling pathway induced by IL-1 also produces inflammatory CAFs, which promote tumor growth (40). In summary, CAF-induced cytokines activate the JAK/STAT signaling pathway and the activated JAK/STAT signaling pathway in turn produces more CAFs, ultimately promoting tumorigenesis and progression. Therefore, inhibition of the JAK2/STAT3 signaling pathway may be a crucial strategy to suppress cancer stemness, plasticity and intercellular signaling between CAFs and cancer cells (Table II) (41-49).

Bufalin, the main active monomer of the clinical drug cinobufacini, has garnered increasing attention for its antitumor activity in various cancers. Research has shown that bufalin can reverse CAF-mediated CRC metastasis by inhibiting the STAT3 signaling pathway (41). Trinilast, an anti-allergic drug that inhibits cytokine release in various inflammatory cells, was recently found to reverse CAF-mediated resistance of NSCLC cells to molecularly targeted drugs both in vitro and in vivo when co-administered with molecularly targeted therapy. This effect is related to the inhibition of CAF-induced upregulation of phosphorylated STAT by trinilast (42). Tocilizumab, a recombinant humanized monoclonal antibody approved by the Food and Drug Administration (FDA) for treating various immune disorders, normalizes active breast CAFs and inhibits their paracrine pro-oncogenic effects by blocking the STAT3 pathway (43).

Curcumin, extracted from the root of the herb turmeric, has been found to inhibit CAF-mediated activation of the JAK/STAT3 signaling pathway, thereby overcoming chemoresistance (44). Additionally, Oroxylin A and resveratrol, both extracted from herbs, have been shown to prevent CAF activation by inhibiting STAT3 phosphorylation (45,46). Similarly, berberine, another compound extracted from Chinese herbs, effectively inhibited CAF-induced STAT3 activation, thereby suppressing the tumorigenicity and growth of nasopharyngeal carcinoma cells (45). A novel mushroom polysaccharide, MPSSS, extracted from food, was shown to be an adjuvant treatment for prostate cancer by inhibiting the JAK2/STAT3 pathway in CAFs (48). β-Carotene, isolated from carrots, inhibited CAF activation by suppressing the IL-6/STAT3 signaling pathway, thus demonstrating its therapeutic potential in cancer progression and metastasis (49).

Current research targeting CAFs through inhibition of the JAK-STAT signaling pathway not only focuses on suppressing CAF activity and function but also addresses overcoming CAF-driven drug resistance and modulating tumor stromal remodeling. Representative agents include Oroxylin A, Resveratrol and Berberine; however, these interventions generally lack high specificity toward CAFs, limiting therapeutic precision and potentially causing off-target effects. Most studies remain at the preclinical stage, providing foundational insights for future clinical translation. Among these approaches, small molecule natural compounds are the most mature, demonstrating effectiveness in inhibiting CAF activation and reversing resistance mechanisms. Importantly, some evidence indicates that such treatments do not merely deplete CAF populations but also induce functional reprogramming of the tumor stroma, broadening therapeutic possibilities. From a translational perspective, these strategies are still in their infancy, highlighting the need to develop more selective JAK-STAT modulators targeting CAFs and prioritize therapies promoting stromal remodeling rather than simple elimination of CAFs, thereby facilitating the safe and effective transition of preclinical findings into clinical applications.

The TGF-β signaling pathway is a superfamily of structurally related multifunctional cytokines, including TGF-β proteins, activins, inhibins, bone morphogenetic proteins (BMPs) and growth and differentiation factors. TGF-β signaling is closely associated with CAF activation or transformation (Fig. 3). For example, bladder cancer cell-derived exosomes have been found to induce the differentiation of fibroblasts into CAFs via TGF-β signaling (50). Similarly, hepatic stellate cells can differentiate into CAFs through the activation of the TGF-β1 signaling pathway, promoting liver metastasis in colon cancer (51). In ovarian cancer, COL11A1 promotes tumor formation and CAF activation through the activation of the TGF-β3 signaling pathway (52). Additionally, the prostate cancer microenvironment can recruit and differentiate mesenchymal stromal cells into CAFs via TGF-β1 (53). Activation of TGF-β signaling is also associated with CAF migration. Evidence suggests that TGF-β signaling activation promotes the collective migration of CAFs by overexpressing tight junction-associated proteins claudin-11 and occluding (54). Furthermore, the CAF-mediated TGF-β pathway promotes cancer progression by regulating cancer cell proliferation, migration, invasion and metastasis (55). Overall, TGF-β signaling and CAFs complement each other: TGF-β signaling influences CAF activity, while CAFs promote cancer progression through TGF-β signaling. Therefore, targeted inhibition of the TGF-β signaling pathway may be an effective strategy to suppress cancer progression and CAFs activation (Table III) (56-79).

Eribulin is a well-tolerated anti-microtubule drug used to treat various tumors. It has been found to 'normalize' CAF function in pancreatic CAFs by a mechanism similar to blocking the TGF-β-induced pathway, suggesting that Eribulin could be used as a CAFs/stromal standardizing drug (56). Preclinical studies reported a self-assembled nanoplatform of hyaluronic acid (HA)-paclitaxel (PTX) (HA-PTX) prodrugs and Marimastat (MATT)-loaded thermosensitive liposomes (LTSLs; MATT-LTSLs) for the treatment of metastatic cancers by downregulating TGF-β expression and blocking CAF activation (57).

Similarly, the TGF-βR1 inhibitor Galunisertib (LY2157299) monohydrate inhibited tumor growth in ovarian cancer by blocking fibroblast activation through downregulation of TGF-β expression (58). Of note, TGF-β1 induced the formation of CAF phenotypes in starved NIH3T3 fibroblasts and xenografted Balb/c mice, thereby promoting breast cancer tumor growth. By contrast, blockade of TGF-β1 induced these effects following the administration of the TGF-β type I receptor kinase inhibitor LY-2157299 (59).

Sulfosuccinimidyl oleate sodium, a CD3 inhibitor, was found to have a significant negative effect on the proliferative and migratory capacity of CAFs and further mechanistic studies were found to be associated with a reduction in the levels of related activation genes (α-SMA, FAP and waveform protein) and cytokines (IL-6, TGF-β and VEGF-α) in nude mice orthotopically implanted with CAFs and HCC cells (60).

The combination of non-steroidal anti-inflammatory drugs (aspirin and ibuprofen) with vincristine effectively inhibited the secretion of TGF-β and IL-6 from CAFs in CRC, thereby reducing chemoresistance to vincristine (61).

Metformin (Met), a first-line drug for diabetes treatment, can disrupt tumor-stromal crosstalk by blocking TGF-β signaling in breast cancer cells (62). Additionally, the cardiac glycoside analog digoxin is a particularly potent CAF blocker, capable of inhibiting TGF-β-induced fibronectin expression at low nanomolar concentrations without causing cytotoxicity (63).

Pirfenidone, an antifibrotic agent and TGF-β antagonist, synergizes with adriamycin to inhibit triple-negative breast cancer by inducing apoptosis in CAFs cells and suppressing CAF proliferation through inhibiting TGF-β expression (64). Furthermore, pirfenidone induces apoptosis in lung CAF cells by inhibiting TGF-β1 (65). Another TGF-β receptor inhibitor, LY2109761, was found to disrupt the crosstalk between cancer cells and CAFs by inhibiting TGF-β expression, leading to a significant reduction in HCC growth and dissemination (66).

Meanwhile, Halofuginone, an old antiparasitic drug for poultry, has been found to inhibit the TGF-β/Smad2/3 signaling pathway, thereby attenuating the promotional effect of CAFs on the migration and invasion of oral squamous cell carcinoma (OSCC) cells (67). Similarly, Nintedanib, a clinically approved multikinase receptor inhibitor, has been found to inhibit TGF-β1-induced expression of a panel of pro-fibrotic activation markers in adenocarcinoma CAFs (68). Additionally, some investigators have used lentiviral vectors encoding BMPs and activin membrane-bound inhibitor to inhibit TGF-β/Smad signaling in human BM-MSCs, thereby preventing them from differentiating into CAFs induced by the TME and the ensuing effects on preneoplastic lesions (69).

Active ingredients from natural products can also target CAFs by modulating the TGF-β signaling pathway. For example, artemisinin and its derivatives have been found to inhibit TGF-β signaling, thereby inactivating cancer-associated fibroblasts and inhibiting cancer metastasis (70). Additionally, tetrahydrocannabinol and cannabidiol, either alone or in combination, inhibit TGF-β-induced interactions between CAFs and cancer cells (71). Furthermore, chestnut extract combined with TGF-β1 has shown synergistic effects on the presence of polymerized α-SMA stress fibers, particularly in CAFs (72).

In CRC, the natural herbal compounds curcumin and chelerythrine chloride have been found to modulate the TGF-β2/Smad2/3 axis, effectively inhibiting cancer cell invasion and migration by intervening in CAF activity (73,74). In breast cancer, curcumin effectively inhibited the CAF phenotype by a mechanism associated with a significant reduction in prostaglandin E2 and TGF-β production (75).

Silibinin, a flavonoid isolated from the fruit of the chrysanthemum plant Silybum marianum, has recently been shown to target CAF-mediated prostate cancer aggressiveness by inhibiting the expression of the TGF-β2-related pathway (76,77).

Despite the considerable therapeutic potential of these natural compounds, their low bioavailability remains a significant limitation. Consequently, the development of nanomedicines to enhance bioavailability has garnered increasing attention. Furthermore, fibroblasts within the TME undergo phenotypic and functional changes, typically driven by interactions with tumor cells; these transformed cells are known as CAFs. Therefore, inhibiting the activation of CAFs can effectively regulate tumor progression at its early stages. For example, mPEG-poly(lactic-co-glycolic acid) (PLGA) nanoparticles loaded with baicalein have been developed, showing high drug loading capacity, stability, biocompatibility and low toxicity. In breast cancer models, this formulation inhibits TGF-β/Smad and TGF-β/MAPK signaling pathways, reduces CAF activation and ultimately enhances chemotherapy efficacy (78).

In pancreatic cancer treatment, a two-stage combined therapy has been introduced, comprising the TGF-β receptor I inhibitor SB525334 and docetaxel micelles. This approach decreases TGF-β secretion and suppresses the activity of myofibroblastic (my)CAFs, identified by α-SMA and FAPα expression, thereby improving therapeutic outcomes (79).

Overall, research on modulating CAFs via inhibition of the TGF-β signaling pathway has not only focused on suppressing the pro-tumorigenic functions and activity of CAFs but also on disrupting tumor-stroma interactions, as exemplified by agents such as Met and pirfenidone. Within the TME, fibroblasts undergo phenotypic and functional transitions typically driven by interactions with tumor cells, resulting in the emergence of CAFs. Notably, targeting the TGF-β pathway can reprogram CAFs, as demonstrated by curcumin, and prevent the differentiation of naïve fibroblasts into CAF phenotypes using compounds such as Nano-baicalein, LY364947 and silibinin, thereby inhibiting tumor initiation at early stages.

Although strategies targeting CAF markers such as FAP have been explored, they do not directly intervene in the key signaling pathways, such as TGF-β, that have been extensively summarized, leaving the precise characteristics of TGF-β-targeted CAF modulation insufficiently understood. Due to the specificity of stromal-targeted therapies, efficacy evaluations have predominantly relied on preclinical models.

In summary, among the various approaches targeting the TGF-β pathway, those involving small molecule natural compounds to reprogram CAF function or prevent fibroblast-to-CAF differentiation appear most mature and selective toward CAFs, offering the advantage of functional stromal remodeling rather than mere depletion. These strategies demonstrate promising prospects for clinical translation, although further studies are needed to optimize specificity and confirm efficacy in human settings.

The NF-κB signaling pathway consists of receptor and receptor proximal signaling interface proteins, the inhibitor of NF-κB (IκB) kinase complex, IκB protein and NF-κB dimer. When cells are subjected to various intracellular and extracellular stimuli, IκB kinase is activated, leading to the phosphorylation and ubiquitination of the IκB protein. This process results in the degradation of the IκB protein and the release of the NF-κB dimer, which is further activated by various post-translational modifications (80).

The classical NF-κB signaling pathway is closely associated with various aspects of cancer biology, including CAF progression, secretory phenotype and immunosuppressive functions. Activation of the NF-κB signaling pathway promotes tumor growth, migration and invasion. Evidence suggests that NF-κB signaling activation facilitates CAF activation (Fig. 4). For instance, circular RNA circCUL2 (hsa_circ_0000234) is specifically expressed in CAFs and in pancreatic ductal adenocarcinoma; circCUL2 induces an inflammatory CAF phenotype through the activation of the MYD88 innate immune signal transduction adaptor (MyD88)-dependent NF-κB signaling pathway, establishing a distinct fibroblast ecological niche for cancer progression (81).

Exosomes from gastric cancer have been found to promote the differentiation of MSCs into CAFs by acetylating the NF-κB P65 signaling pathway, thereby inducing aberrant metabolic and inflammatory activation (82). CD146, a cell membrane protein, has been associated with various human cancers. A study found that CD146 knockdown promoted CAF activation by potentially inducing the production of pro-tumorigenic factors through the regulation of NF-κB activity (83). Eukaryotic translation initiation factor 4A3 (EIF4A3), a core component of the exon junction complex, has a crucial role in pre-mRNA splicing. Evidence suggests that EIF4A3 stabilizes the expression of long non-coding RNA AGAP2-AS1, activates CAFs through MyD88/NF-κB signaling and thus exacerbates lung cancer, revealing a new regulatory axis in lung cancer (84).

In summary, activation of the NF-κB signaling pathway facilitates the activation or transformation of CAFs and subsequently promotes tumor progression. Conversely, inhibition of the NF-κB pathway can eliminate CAFs and increase drug sensitivity. Genes in the NF-κB signaling pathway may represent potential cancer therapeutic targets (Table IV) (85-93).

NF-κB inhibitors can be used alone or in combination with chemotherapeutic agents to treat cancer and prevent recurrence. For example, chloroquine (CQ) and hydroxychloroquine (HCQ) are known antimalarials that have been successful in treating autoimmune and oncologic diseases. CQ and HCQ normalize the tumor-associated vascular system and stimulate cancer-associated fibroblasts through mechanisms related to the regulation of the Toll-like receptor 9 (TLR9)/NF-κB pathway (85). Melatonin has been reported to indirectly reduce the proliferation and invasion of gastric cancer cells by affecting cancer-associated fibroblasts, with the mechanism involving the regulation of the NF-κB pathway (86). Although REPERTAXIN is an IL-8 receptor (CXCR1/2) inhibitor, it effectively attenuates the protection of CAFs against CD8+ T cytotoxicity-resistant cancer cells by a mechanism that may be related to reduced levels of phosphorylated (p)-P38, p-JNK and p-NF-κB (87). In addition, bepotastine, an approved H1 antihistamine, inhibited the senescence-associated secretory phenotype (SASP) of CAFs induced by poly (ADP-ribose) polymerase inhibitors (PARPis) at clinical serum concentrations. It was further demonstrated that bepotastine attenuated PARPi resistance in fibroblast-promoted tumors in three-dimensional organotypic cultures and homologous recombination-deficient patient-derived xenograft models. Mechanistically, bepotastine inhibits PARPi-triggered SASP by inhibiting NF-κB signaling independent of histamine H1 receptors (88).

Additionally, Jianpi Jiedu Recipe (JPJDR), a classic traditional Chinese medicine prescription, can prevent CRC liver metastasis by blocking CAF activation through the regulation of the integrin β-like 1 (ITGBL1)-TNF-α-induced protein 3 (TNFAIP3)-NF-κB signaling pathway, providing experimental evidence for its clinical application in preventing and treating CRC metastasis (89). Furthermore, the aforementioned polysaccharide MPSSS extracted from shiitake mushrooms can alter the function of prostate CAFs by activating the TLR4-NF-κB pathway, providing a new strategy for comprehensive tumor treatment (90). Similarly, ligustilide can modulate the immunosuppressive function of CAFs by affecting the TLR4-NF-κB pathway, thereby restoring T-cell proliferation previously inhibited by CAF supernatant (91).

CAFs have been suggested to be an important factor in inducing early metastasis and postoperative recurrence tendency in triple-negative breast cancer (TNBC) due to its characteristics of inducing dysfunction and promoting tumor metastasis. Chen et al (92) found that Bruceine D, an active compound derived from the Chinese herb Brucea javanica, inhibited CAFs-promoted TNBC metastasis by suppressing Notch1-Jagged1/NF-κB (p65) signaling. In addition, the herb is commonly used in clinical practice against Scutellaria barbata D. Don and Scleromitrion diffusum (Willd.) R.J. Wang for its anti-tumor properties. Using a combination of bioinformatics and in vitro and in vivo experiments, researchers have found that the herb inhibits the progression of TNBC through inhibition of NF-κB activation triggered by CAFs-derived IL-6 in S. barbata and S. diffusum (93).

Overall, research exploring the regulation of CAFs through inhibition of the NF-κB signaling pathway has extended beyond merely suppressing the pro-tumorigenic activities and activation of CAFs, as seen with agents such as JPJDR and Ligustilide, to also enhancing chemosensitivity with compounds such as Bepotastine. Additionally, CAF-induced immunosuppression remains a major barrier to effective cancer therapy and studies have demonstrated that targeting the NF-κB pathway with drugs such as MPSSS and Repertaxin can effectively mitigate immune resistance, thus opening new avenues to potentiate immunotherapeutic outcomes. Although therapies directed at CAF surface markers have been explored, they frequently bypass critical intracellular signaling cascades, including NF-κB, that govern CAF behavior, leaving the precise characteristics of NF-κB-targeted CAF interventions insufficiently defined. Furthermore, due to the complexity and context-dependent nature of stromal-targeted treatments, current evaluations of therapeutic efficacy primarily rely on preclinical models.

In summary, the most advanced and selective approaches targeting the NF-κB pathway in CAFs combine inhibition of CAF activation with the reversal of immunosuppressive functions, favoring stromal reprogramming over outright depletion. These strategies hold substantial promise for clinical translation, contingent upon further refinement to ensure specificity and durable therapeutic effects in patients.

FAP, a membrane-bound glycoprotein, is upregulated in CAFs but not in normal fibroblasts (94). FAP is positive in >90% of human cancers, making it a promising universal target for solid tumors (95). A phase I clinical study found that sibrotuzumab can inhibit tumor progression by specifically targeting and inhibiting CAFs in patients with FAP-positive cancers (96). Another clinical trial with iodine 131-labeled monoclonal antibody F19 (131I-mAbF19) demonstrated inhibition of tumor metastasis by recognizing FAP-specific depletion of CAFs (97).

Activated CAFs and their secreted collagen contribute to a dense fibrotic stroma that impedes drug penetration and characterizes pancreatic ductal adenocarcinoma (PDAC) as an immune-desert tumor. In a clinical study on PDAC, combination treatment with paricalcitol and hydroxychloroquine alongside gemcitabine reduced the number of fibroblasts expressing Ki67, FAP and SMA, while concurrently decreasing autophagy-related transcripts (98), indicating that this regimen enhances chemosensitivity and improves therapeutic outcomes in PDAC. Similarly, preclinical studies have demonstrated that in vivo administration of FAP-targeted chimeric antigen receptor macrophages (FAP-CAR-M), engineered to eliminate activated CAFs marked by FAP, markedly reduced markers of activated CAFs (FAP), collagen volume fraction and Col1a1 secretion in murine models. These findings suggest that FAP-CAR-M represent a potential therapeutic strategy to overcome the fibrotic barrier and thereby potentiate chemotherapy and immunotherapy against PDAC (99).

Additionally, in mouse models of epithelial-derived solid tumors, preclinical studies have found that PT630 can target FAP to reduce the content of CAFs and blood vessel density in tumors, thereby inhibiting stromatogenesis, angiogenesis and ECM remodeling, ultimately suppressing tumor growth (100). AMD3100, a CXCL12 receptor chemokine (C-X-C motif) receptor 4 inhibitor removes FAP-expressing CAFs to immunocontrol tumor growth in PDA-bearing mice, revealing the anti-tumor effects of immunotherapeutic antibodies (101). Natural active ingredients have great potential in targeting FAP and thus inhibiting CAFs.

Oxidized omphalosine (Om) is an alkaloid compound and one of the active components of bitter ginseng in Chinese medicine. Om effectively inhibits the activation of CAFs and promotes T-cell infiltration across CAFs by downregulating the expression of FAP and α-SMA (102). This intervention may lead to promising therapeutic directions for the treatment of TNBC.

Trigonelline (TGN), an alkaloid found in medicinal plants such as Coffea spp. and Trigonella foenum-graecum (fenugreek), has exhibited notable anticancer properties across various malignancies. A recent study revealed that TGN reduces fibroblast-to-CAFs conversion by downregulating α-SMA and FAP expression in bladder cancer, indicating its ability to normalize the TME. These results suggest that TGN has potential to alleviate chemoresistance and thereby enhance chemotherapeutic efficacy (103).

Similarly, rosmarinic acid (RA) treatment markedly attenuated CAF activation markers and reversed EMT-related alterations in cancer cells, resulting in reduced tumor growth in CAF-enriched xenograft models. The combination of RA with gefitinib exhibited enhanced antitumor effects compared with gefitinib monotherapy (104). Echinocandin A (Ech A), a marine substance isolated from sea urchins, is a strong antioxidant. A study has reported that Ech A attenuates CAFs-induced lung cancer cell migration, which is accompanied by a decrease in the expression levels of CAF markers, waveform proteins and FAP (105).

In addition, nanomaterial-based drug delivery systems are particularly promising for cancer therapy. Leveraging the self-assembly properties of amphiphilic peptides, researchers developed a smart transformer-like drug delivery system based on cleavable amphiphilic peptides that specifically respond to FAP-α expressed on CAFs in the TME, achieving enhanced drug delivery and promising antitumor effects (106). In addition, a CAF-associated ITGB1-inactivating peptide-rich membrane nanodelivery system (designated PMNP-D) has been shown to target both CAFs and tumor cells to enhance chemotherapy by promoting drug infusion. After prolonged blood circulation and active targeting of the tumor site, PMNP-D triggers the release of FNIII14 in response to CAFs overexpressing FAP-α, which binds to ITGB1 and inhibits the biological function of CAFs to produce stromal matrix, thereby loosening the condensed stromal structure and enhancing the permeability of nanotherapeutic agents in the tumor (107). In breast cancer treatment, a novel polymeric nanoparticle system targeting CAFs has been developed by encapsulating synthetic 8-O-methylfusarubin (OMF) within nanoparticles modified with anti-FAP antibodies (OMF@NPs-anti-FAP). This formulation showed markedly enhanced cytotoxicity in 3D spheroid models. Compared with low-FAP-expressing cells such as MCF-10A, HDFa and PC-B-142 CAFs, the high-FAP-expressing PC-B-132 CAF cells exhibited markedly higher levels of cell death, as confirmed by flow cytometry. These findings suggest that the developed high-specificity OMF-loaded polymeric nanoparticle system may serve as a promising nanoplatform for improved breast cancer therapy (108). Similarly, in breast cancer, a biomimetic nanodrug system (FAP-C NPs) was engineered by fusing 4T1 cell-derived extracellular vesicles with FAP single-chain antibody fragments to form a biomimetic shell around calcipotriol-loaded PLGA nanoparticles. Experimental evidence demonstrated that FAP-C NPs could revert activated CAFs to a quiescent state, thereby neutralizing their pro-tumor functions, inhibiting cancer cell stemness, promoting dendritic cell maturation and alleviating the immunosuppressive effects of CAFs on lymphocytes. Furthermore, when combined with radiotherapy, this biomimetic nanosystem inhibited CAF activation, enhanced radiosensitivity and elicited a robust antitumor immune response, evidenced by a twofold increase in cytotoxic T-cell infiltration in the TME, ultimately suppressing tumor growth effectively. These results highlight the great potential of FAP-C NPs as a targeted therapeutic strategy in breast cancer treatment (109).

Meanwhile, phototherapeutic techniques have been used to target CAFs in tumors. Investigators developed a novel near-infrared photoimmunotherapy technique focusing on FAP, which specifically induced rapid cell death in vitro and in vivo mouse xenograft models with no adverse effects (110). Notably, the combination of photodynamic therapy and nanoparticles could substantially improve the ability to eradicate CAFs and induce broad-spectrum anticancer effects. Researchers used ferritin, a compact protein cage of nanoparticles, as a photosensitizing carrier and coupled FAP-specific single-chain variable fragments to the surface of ferritin to create a nanoparticle-based photoimmunotherapy (nano-PIT). This method effectively eliminated CAFs from tumors by light irradiation enabled by nano-PIT while causing minimal damage to healthy tissues due to the localized nature of the treatment (111).

Other researchers developed a photodynamic therapy method called αFAP-Z@FRT, which is based on ZnF16Pc (a photosensitizer) loading and FAP-specific single-chain variable-fragment conjugated apoferritin nanoparticles. This method is also effective in eradicating CAFs from tumors without causing systemic toxicity (112). The aforementioned results imply that the FAP-targeting polymersomes-based delivery system has the potential to be an excellent tool for cancer therapy.

FAP represents the most extensively studied and clinically advanced target among the various strategies aimed at modulating CAFs. Therapeutic agents targeting FAP not only inhibit CAF activation, thereby attenuating tumor progression and the fibroblast-to-CAF transition, as exemplified by compounds such as RA and Echinocandin A, but also serve as direct targets for drug delivery systems that selectively suppress CAFs. Noteworthy examples include transformable peptide nanocarriers, FNIII14 peptide-enriched membrane nanocarriers and polymeric nanoparticles loaded with 8-O-methylfusarubin, all of which have demonstrated promising efficacy across diverse cancer models. Among the distinct molecular pathways implicated in CAF regulation, approaches centered on FAP inhibition stand out for their maturity, specificity and capacity to reprogram the tumor stroma rather than solely deplete fibroblast populations. Consequently, FAP-targeted interventions exhibit superior selectivity towards CAF populations and hold significant translational potential, underscoring their leading role in the clinical advancement of matrix-focused cancer therapies (Table V) (96-109,112).

Ferroptosis is a recently characterized, iron-dependent form of programmed cell death that is mechanistically distinct from apoptosis, necrosis and autophagy. It is driven by divalent iron and ester oxygenases that catalyze peroxidation of polyunsaturated fatty acids within membrane phospholipids, leading to lethal lipid-reactive oxygen species (ROS) accumulation. This lipid peroxidation is normally counteracted by the glutathione system, with glutathione peroxidase 4 (GPX4) as the core enzyme; decreases in GPX4 activity and glutathione availability sensitize cells to ferroptosis (124). Within the TME, CAFs modulate therapy response in part by suppressing ferroptosis, thereby fostering drug resistance. CAFs-secreted exosomal miR-522, for example, targets arachidonate 15-lipoxygenase to block lipid-ROS accumulation and inhibit ferroptosis in cancer cells, ultimately reducing chemotherapy sensitivity (125). Similarly, CAFs-derived exosomal miRNAs that target acyl-CoA synthetase long chain family member 4 (ACSL4) inhibit ferroptosis and induce gemcitabine resistance in pancreatic cancer cells (126). Beyond exosomal signaling, CAFs can reprogram cysteine metabolism to boost glutathione synthesis and increase resistance to ferroptosis in pancreatic cancer (127). These findings collectively support ferroptosis as a promising axis for CAFs-focused intervention. Although research on ferroptosis activators is broad, relatively few small molecules have been designed to target CAFs by mediating ferroptosis; accordingly, this article summarizes small-molecule approaches to modulate ferroptosis in the context of CAFs (Fig. 5).

Importantly, CAF-derived signals are context dependent and can also sensitize tumors to ferroptosis. CAFs exosomal disheveled binding antagonist of beta catenin 3 antisense 1 (DACT3-AS1) acts as an inhibitory regulator of malignant transformation and oxaliplatin resistance by inducing ferroptosis, characterized by decreased GPX4 and solute carrier family 7 member 11 (SLC7A11) expression, reduced GSH levels and suppression of oxaliplatin-treated cells; the ferroptosis inhibitor ferrostatin-1 reverses these effects, indicating that DACT3-AS1 engages ferroptotic mechanisms in oxaliplatin-treated gastric cancer cells (128). In OSCC, a podoplanin-positive CAFs subset promotes invasiveness by inhibiting ferroptosis in tumor cells via the FTX/flap structure-specific endonuclease 1 (FEN1)/ACSL4 signaling cascade; treatment with the ferroptosis activator RSL-3 suppresses the tumorigenic potential of OSCC cells overexpressing FEN1 in vitro and in vivo (129). Leveraging the prevalence of FAP overexpression in >90% of human tumors, exocrine-like nanovesicles (eNVs-FAP) derived from FAP-engineered tumor cells have been developed as a tumor vaccine that promotes tumor ferroptosis and inhibits growth by releasing interferon-γ (IFN-γ) from cytotoxic T lymphocytes while depleting FAP+ CAFs (130). Ferroptosis also intersects with antitumor immunity: In gastric cancer, CAFs as a major immunosuppressive component can induce ferroptosis in natural killer (NK) cells through iron regulation, impairing their cytotoxic function and promoting tumor progression and immune escape. In patient-derived organoid models, functional targeting of CAFs using the iron chelator deferoxamine combined with a follistatin like protein 1-neutralizing antibody alleviates CAFs-induced ferroptosis in NK cells and enhances their cytotoxicity against gastric cancer (131). Similarly, CAFs-induced resistance to immunotherapy is closely linked to anoctamin 1 (ANO1)-mediated inhibition of cancer cell ferroptosis; ANO1 upregulates nuclear factor erythroid 2-related factor 2/SLC7A11 via a PI3K-Akt-dependent pathway, whereas the ferroptosis agonist erastin reverses ANO1-driven suppression of lipid ROS and malondialdehyde and mitigates ANO1's malignant effects (132).

Together, these studies delineate a bidirectional relationship between CAFs and ferroptosis: CAFs can impede ferroptosis to support drug resistance and immune evasion, yet they can also be targeted or leveraged to restore ferroptotic vulnerability and resensitize tumors. Practically, integrating ferroptosis modulators, whether small molecules such as RSL-3 and erastin or targeted nanovesicle platforms such as eNVs-FAP, into CAF-centric strategies offers a route to counteract stromal protection, enhance chemotherapy efficacy and strengthen antitumor immunity.

Apoptosis is a genetically programmed, autonomous and orderly form of cell death that preserves tissue homeostasis by removing damaged or superfluous cells, thereby enabling improved adaptation to the microenvironment. Within the TME, CAFs are pivotal drivers of tumorigenesis, progression and migration; accordingly, eliminating CAFs or attenuating their tumor-promoting activity can facilitate tumor immunotherapy (133). It has been reported that CAFs exhibit tumor-promoting properties by inhibiting apoptosis of tumor cells; however, evidence also suggests that CAFs may stimulate apoptosis of tumor cells (134). These observations position apoptosis as a tractable regulatory node for modulating CAF activity. Although the available evidence suggests that CAF apoptosis may be a double-edged sword, wherein excessive depletion could perturb stromal integrity or provoke maladaptive remodeling, most current strategies intentionally promote CAF apoptosis to restrain tumor progression. Pharmacologic and repurposed agents illustrate this approach. Disulfiram/copper (DSF/Cu), noted for clinical promise based on its anticancer activity and safety, induces apoptosis in nasopharyngeal fibroblasts via an aldehyde dehydrogenase-independent mechanism; in vivo, DSF/Cu combined with cisplatin (CDDP) is well tolerated and markedly suppresses nasopharyngeal tumor growth both in tumor cell models and in 5-8F xenografts (135). Clinically advanced agents such as bortezomib and panobinostat have likewise emerged as anti-CAF candidates: They reduce the viability of multiple patient-derived CAF populations by inducing caspase-3-mediated apoptosis, with combination therapy outperforming either monotherapy in vitro and in xenografts of mouse breast cancer cells with mouse CAFs (136). Pirfenidone, an antifibrotic drug approved for idiopathic pulmonary fibrosis, triggers apoptotic death in pulmonary CAFs at high concentrations and low-dose combinations with cisplatin further increase CAF death in both co-culture systems and in vivo settings (65). Natural compounds add complementary mechanisms: Curcumin and cinnamaldehyde, extracted from Chinese herbs, induce apoptosis and cell-cycle arrest in prostate cancer CAFs via ROS-mediated endoplasmic reticulum (ER) stress and intrinsic apoptotic pathways, respectively (137,138).

Nanotechnology has expanded the toolkit for selectively inducing apoptosis in CAFs while potentially improving therapeutic indices. Nab-paclitaxel, an effective agent against intrahepatic cholangiocarcinoma (IH-CCA), more efficiently destroys CAFs than its prototype paclitaxel in a rat model of thioacetamide-induced spontaneous desmoplastic IH-CCA (139). Biodegradable, negatively charged ONP-302 nanoparticles have been used to induce apoptosis in CAFs within the TME (140). Targeted delivery systems further enhance specificity: Navitoclax-loaded nanoliposomes modified with the FH peptide (FH-SSL-Nav), which binds tenascin C predominantly expressed by CAFs, selectively engage apoptotic pathways in CAFs (141); similarly, nucleic acid aptamer-modified PLGA nanoemulsions effectively target CAFs and induce their apoptosis (142).

Collectively, these data support apoptosis-oriented modulation of CAFs as a rational strategy to weaken stromal support for malignancy and to potentiate standard anticancer therapies. Conceptually, the convergence of repurposed small molecules and targeted nanocarriers offers a path to enhance selectivity, reduce off-target toxicity and integrate CAF apoptosis with cytotoxic or targeted regimens. Given the context dependence of stromal biology, careful attention to dosing, scheduling and readouts of on-target activity (e.g., cleaved caspase-3 and ER-stress biomarkers in CAFs, alongside stromal remodeling endpoints) will be essential to maximize antitumor benefit while preserving necessary tissue homeostasis, without altering the fundamental rationale and evidence base aforementioned.

Autophagy is a catabolic process in which cytoplasmic proteins or organelles are sequestered into double-membrane vesicles and subsequently fuse with lysosomes to form autolysosomes that degrade their contents. Emerging evidence indicates that autophagy contributes to the metabolic and signaling interplay between tumors and CAFs, with CAFs promoting tumor growth by supplying nutrients to cancer cells through autophagic activity (143). Consistent associations between autophagy and CAF progression have been reported across breast, and prostate, cancers, supporting autophagy as a tractable node for modulating CAFs-mediated tumor support (144). Conceptually, therapeutic benefit can arise from autophagy modulation in either direction, but most current efforts emphasize inhibition of autophagy within CAFs to blunt their pro-tumor functions, while in selected contexts induction of autophagy in cancer or stromal cells can also counteract CAF-driven malignant behaviors (134).

Among autophagy inhibitors, chloroquine has been shown to abrogate the stimulatory effects of CAFs on tumor growth and to suppress the pro-carcinogenic homologous TLR4/NF-κB signaling pathway in a mouse xenograft model (145). In HCC models, chloroquine also inhibits CAFs-induced activation of autophagic flux in cancer cells, leading to light chain (LC)3-II accumulation and increased LC3 puncta, thereby preventing CAFs from enhancing stem cell-like properties in these cells (146). In parallel, matrix caveolin-1 (Cav-1) deficiency has emerged as a stromal biomarker of CAFs associated with poor outcomes in breast cancer and ductal carcinoma in situ; chloroquine or other autophagy/lysosomal inhibitors may act as anticancer agents by therapeutically restoring stromal Cav-1 expression in CAFs (147). Complementing these inhibitory strategies, several interventions leverage autophagy induction to disrupt CAF-related tumor support: Polygonatum polysaccharides extracted from Chinese herbs stimulate autophagy and inhibit the growth of prostate CAFs, suggesting a novel approach centered on limiting prostate CAF expansion (148); the naturally occurring polyphenol resveratrol counters IL-6-induced migration of ovarian cancer cells by inducing autophagy in migrating frontier cells, thereby attenuating invasive and metastatic behavior (149); and resveratrol together with its analogue 4,4'-dihydroxy-trans-stilbene reduces lung carcinoma tumor mass through enhanced autophagy, which blocks the phenotypic transformation of normal fibroblasts into CAFs (150).

Taken together, these findings delineate autophagy as a context-dependent lever in the tumor-stroma ecosystem: CAF-driven autophagy can fuel tumor growth, yet judicious modulation, predominantly inhibition within CAFs and in specific scenarios induction within cancer or stromal compartments, can dismantle CAF-mediated support for malignancy. This logic argues for cell type-specific, endpoint-anchored strategies that track autophagy dynamics (such as LC3-II accumulation and puncta) alongside stromal phenotypes such as Cav-1, enabling the selection of inhibition vs. induction to achieve sustained suppression of CAF-driven tumor progression without undermining essential tissue homeostasis.