In recent years, use of exosomes is one of the important approaches to treat cancer. Mesenchymal stem cells are multipotent stem cells which are very putative sources for modulating the immune system and importantly inhibiting immune responses against tumor cells. Small extracellular vesicles (small EVs) are extracted from mesenchymal stem cells can have therapeutic approaches for delivering targeted drugs to cancer cells and also tumors via regulation of signaling pathways.There are challenges in use of exosomes in cancer treatment which need to be improved. Engineering in small EVs can recover the role of exosomes such as drug delivery and therapeutic tools. There are preclinical and clinical studies in the field of mesenchymal stem cells derived from small EVs which demonstrates efficacy of these approaches in the field of cancer.In consideration of problems in large scale production and so on, engineered small EVs as treatment approaches for cancers, it is resulted that they retain most characteristics of cells which are derived from, are responsible for their immunomodulatory impacts driving positive changes in the tumor microenvironment.